Deposition: Defendant, Dr. Abrar Chaudhry
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1 IN THE STATE COURT OF DEKALB COUNTY
STATE OF GEORGIA
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3 STEFAN LANE and JANE ß CIVIL ACTION FILE NO.
LANE, ß 19A77517
4 ß
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5 Plaintiffs, ß
ß
6 vs. ß
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7 EMORY HEALTHCARE, INC.; ß
EMORY PHYSICIANS GROUP, ß
8 LLC; PRINCIPALS of the ß
INDIVIDUAL DEFENDANTS; ß
9 ABRAR CHAUDHRY, M.D.; ß
RYAN A. MARTEN, M.D.; ß
10 BRYAN LEE MAYS, RN; ß
CHARICE JORDAN, PA-C; ß
11 MAHMOUD OBIDEEN, M.D.; ß
and JOHN/JANE DOE 1-5, ß
12 ß
ß
13 Defendants. ß
ß
14 ~~~~~~~~~~~~~~~~~~~~~~~~~
15 VIDEOTAPED DEPOSITION OF
ABRAR CHAUDHRY, M.D.
16 CONDUCTED REMOTELY
17
10:16 a.m. EST
18 Monday, the 17th day of August 2020
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21 Blanche J. Dugas, CRR, RPR, CCR No. B-2290
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1 APPEARANCES OF COUNSEL VIA VIDEOCONFERENCE
2 On Behalf of the Plaintiffs:
DANIEL E. HOLLOWAY, Esquire
3 Bell Law Firm
Suite 2000
4 1201 Peachtree Street, NE
Atlanta, Georgia 30361
5 (404) 249-6768
(404) 249-6764 (facsimile)
6 dan@belllawfirm.com
7 On Behalf of the Defendants:
B. DAVID LADNER, Esquire
8 Bendin Sumrall & Ladner, LLC
One Midtown Plaza, Suite 800
9 1360 Peachtree Street, NE
Atlanta, Georgia 30309
10 (404) 671-3100
(404) 671-3080 (facsimile)
11 dladner@bsllaw.net
12 Also Present:
Huseby Technician
13 Paige McKinney
Tammie Hudson
14 Janet Lane
Stefan Lane
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1 INDEX OF EXAMINATION
2 EXAMINATION PAGE
3 EXAMINATION 5
BY MR. HOLLOWAY
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5 - - -
6 INDEX TO EXHIBITS
7 EXHIBIT DESCRIPTION PAGE
8 1 Admissions - stroke and tPA 22
9 2 Admissions - tPA and last 25
known well
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3 Admissions - TIA 27
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4 Admissions - TIA and tPA 28
12 window
13 5 Admissions - neuro 31
monitoring frequency
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6 Neuro monitoring - 2 hour 32
15 timeline
16 7 Neuro monitoring - 37
four-hour timeline
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8 Admissions - big picture 89
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9 Timeline - December 14th 147
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10 Timeline for the morning of 154
20 December 15th
21 11 Timeline for the evening of 186
December 15th
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12 Timeline - December 16th 198
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13 Timeline - December 17th 199
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14 Timeline - December 18th 201
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1 15 Timeline - December 19th 202
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(Original Exhibits 1 through 15 have
3 been attached to the original transcript.)
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1 Videotaped Deposition of Abrar Chaudhry, M.D.
August 17, 2020
2
3 ABRAR CHAUDHRY, M.D.,
4 having been first duly sworn, was examined and
5 testified as follows:
6 MR. HOLLOWAY: Okay. This will be the
7 deposition of Dr. Abrar Chaudhry in the
8 case of Lane versus Emory. This deposition
9 is being taken for all purposes allowable
10 under the Civil Practice Act.
11 Do we agree that the witness can be
12 properly sworn remotely?
13 MR. LADNER: We are.
14 MR. HOLLOWAY: I propose that we
15 stipulate that all objections are reserved
16 except those going to the form of the
17 question or responsiveness of the answer.
18 Is that agreeable?
19 THE WITNESS: That's agreeable.
20 EXAMINATION
21 BY MR. HOLLOWAY:
22 Q. Good morning, Dr. Chaudhry.
23 A. Good morning.
24 Q. My name is Dan Holloway. I represent Stefan
25 and Janet Lane in this case. Please state your name
6
1 for the record and give us the spelling.
2 A. Abrar Chaudhry. A-B-R-A-R, C-H-A-U-D-H-R-Y.
3 Q. You're a defendant in this case?
4 A. Yes.
5 Q. In December of 2017, you were a physician
6 employed by The Emory Clinic, Inc. working at Emory
7 Johns Creek Hospital; is that right?
8 A. Yes.
9 Q. The Emory Clinic, Inc. is also a defendant
10 in this case; right?
11 A. Yes.
12 Q. Are you still employed by them?
13 A. Yes.
14 Q. Still working at Emory Johns Creek Hospital?
15 A. Yes.
16 Q. The Emory Johns Creek Hospital is part of
17 the Emory Healthcare system; right?
18 A. Yes.
19 Q. And Emory Healthcare markets Emory Johns
20 Creek Hospital as a primary stroke center; correct?
21 A. Yes.
22 Q. How long have you worked at Emory Johns
23 Creek?
24 A. Since 2015. So approximately five years.
25 Q. Do you routinely treat stroke patients?
7
1 A. I do admit them.
2 Q. And after admitting them, do you attend
3 them?
4 A. Yes. And most of the time, it's if they
5 need help for the neurologist on call.
6 Q. So you -- you routinely are responsible as
7 the attending for stroke patients?
8 A. Yes.
9 Q. And you treat them in conjunction with a
10 consulting neurologist.
11 A. Yes.
12 Q. About how many stroke patients do you think
13 you have treated ballpark?
14 A. I don't remember.
15 Q. Are we talking in the tens, in the hundreds?
16 A. I'd say, if I just have to guess, maybe 100,
17 close to that.
18 Q. Okay. Now, as we go forward, from time to
19 time I may use the phrase "standard of care." By that
20 phrase, I mean the degree of care and skill ordinarily
21 exercised by members of the medical profession
22 generally, under the same or similar circumstances and
23 like surrounding conditions.
24 Do you understand that definition and can
25 you keep it in mind for the duration of this
8
1 deposition?
2 A. Sure.
3 Q. When I refer to Emory, unless I say
4 otherwise, I'm talking about Emory Johns Creek
5 Hospital or The Emory Clinic, Inc. Can you keep that
6 in mind for the duration?
7 A. Yes.
8 Q. If you find any of my questions unclear or
9 confusing, please let me know. If you think any of my
10 questions cannot be answered because the question is
11 premised on a factual error, please say so and tell me
12 what the factual error is. And if you feel like the
13 answer to any of my questions requires an explanation,
14 please feel free to give the explanation, but I ask
15 that you answer the question directly first before the
16 explanation. Fair enough?
17 A. Sure. Yeah.
18 Q. Now, you understand that there is no
19 allegation in this case that you or anybody else acted
20 with malice. Do you understand that?
21 A. Yes.
22 Q. What do you know about the harms that Stefan
23 Lane lives with because of the stroke he suffered at
24 Emory?
25 A. I do not know.
9
1 Q. Have you done anything to try to find out
2 what harm the stroke caused?
3 A. No, I have not.
4 Q. When did you first learn that you were part
5 of a lawsuit over the treatment of Stefan Lane?
6 A. It was more than a year ago when I was
7 contacted by part of the administration at Emory that
8 I had to meet with David.
9 Q. Who contacted you?
10 A. I believe it was -- I don't -- I got an
11 e-mail, I think. I don't exactly remember. It was --
12 I think it was Tammie Hudson.
13 Q. And she is part of the administration at The
14 Emory Clinic?
15 A. Yeah. In risk --
16 Q. Is that -- sorry.
17 A. In that department.
18 Q. In what department?
19 A. I don't know her specific job designation.
20 Q. Okay. But she -- she -- as you understand
21 it, she works in the risk management department for
22 Emory?
23 A. Yes.
24 Q. Have you ever been sued before?
25 A. No.
10
1 Q. I imagine it was an unpleasant thing to
2 learn about.
3 A. This case?
4 Q. Yeah.
5 A. Yeah, of course. Yeah.
6 Q. Memorable, I would guess. Yes?
7 A. In what sense?
8 Q. Well, the kind of thing that might give you
9 a jolt and stick in your memory; is that fair?
10 A. Yeah. After reviewing everything that
11 happened, yes, it's definitely something that is
12 really tough that Mr. Lane and the family went
13 through.
14 Q. So you took the lawsuit seriously when you
15 learned about it?
16 A. Of course.
17 Q. And in part, you took it seriously because
18 obviously it implicates your own interests. That's
19 part of it.
20 A. I mean, the deficits and everything and the
21 suffering and the pain that everybody -- that they
22 went through, and that's -- that's uncomfortable for
23 me.
24 Q. Right. Part of the -- let me go -- let me
25 go back to what I was asking about specifically first,
11
1 though. Part of the reason you took the lawsuit
2 seriously is because it implicates your own personal
3 interests; true?
4 A. Part of -- yeah. Yeah, because I was
5 directly involved in their care and then they
6 eventually ended up suffering. So, yes, definitely I
7 took it seriously.
8 Q. Tell me -- tell me -- I asked this a minute
9 ago, but tell me what you know as you sit here right
10 now about the suffering that Stefan and Janet have
11 endured because of the stroke.
12 A. So this is what I know, that they still have
13 left-sided upper and lower extremity weakness and have
14 difficulty maintaining their activities and their
15 daily life, yeah.
16 Q. Okay. And part of the reason you took the
17 lawsuit seriously when you learned about it was
18 because it says that there was a series of acts of
19 medical negligence that caused serious harm.
20 That's -- I'm not -- I'm not asking you to admit that
21 there was negligence, but you took the allegation
22 seriously; right?
23 A. Yeah.
24 Q. When you learned about the lawsuit, did you
25 want to find out what happened with the treatment of
12
1 Stefan Lane?
2 A. So I was given some records to review, and I
3 reviewed especially my care, what I provided and what
4 I did, et cetera.
5 Q. When were you given those records to review?
6 A. I don't exactly remember, but it was after I
7 met David.
8 Q. Okay. So let me go back. When you first
9 learned about the lawsuit, did you want to find out
10 what happened with the treatment of Stefan Lane?
11 A. I did not personally review it at that time.
12 Q. That's not quite the question. The question
13 is: Did you want to find out what happened with the
14 treatment of Stefan Lane?
15 A. Yeah, I wanted to find out. Yeah.
16 Q. Did you want to learn the details of what
17 happened with Stefan?
18 A. Of course, yeah.
19 Q. Did you have access to Stefan's medical
20 records from Emory?
21 A. Since I work there and I was involved in
22 that case, and, yes, I could -- I could go into a
23 certain area of the chart and put in the information
24 and then review it. Yes, I could do that.
25 Q. Did anything prevent you from learning the
13
1 details of what happened with Stefan at Emory?
2 A. So I basically wasn't told to review
3 everything. I basically reviewed the care that I
4 provided, and up until -- when -- the time when I was
5 involved in the case, I reviewed that part.
6 Q. I hear you, but I'm asking a slightly
7 different question. Did anything prevent you from
8 learning the details of what happened with the
9 treatment of Stefan at Emory?
10 MR. LADNER: And I'll just object to
11 the extent it invades the attorney-client
12 privilege or anything we told him to do or
13 not to do. But subject to that objection,
14 he can answer.
15 THE WITNESS: Yeah, I was basically --
16 I basically just wanted to review my own
17 care that I provided, and for the rest of
18 it, I was told not to do so.
19 MR. LADNER: And let me just -- don't
20 tell him anything we talked about, Dr.
21 Chaudhry.
22 THE WITNESS: Uh-huh (affirmative).
23 MR. LADNER: Or anything we told you.
24 THE WITNESS: Okay.
25 Q. (By Mr. Holloway) Yeah, and just as a
14
1 general matter going forward, if any of my questions
2 would -- in answering any of my questions, don't tell
3 me about the substance of conversations between you
4 and your lawyers.
5 A. Okay.
6 Q. How did you come to get into medicine?
7 A. So, yeah, medicine, always I wanted to
8 become a physician. There was -- several family
9 members are physicians and I just wanted to become a
10 physician all my life basically.
11 Q. From --
12 A. Childhood. Yeah. Yeah. From very --
13 beginning from early school even.
14 Q. It was -- I'm hearing you say that it was
15 sort of a family tradition of being a doctor.
16 A. Yes. Basically my uncle was my influence,
17 and he has been a physician since late '60s and he --
18 he specialized in -- he went to England and then he --
19 he still practices and he runs a free clinic. So he
20 was a big inspiration for me and he still practices.
21 Q. What kind of clinic does he run?
22 A. It's a -- it's more of like a primary care
23 versus -- and a cardiology clinic. He's a
24 cardiologist.
25 Q. Where does he run the clinic?
15
1 A. It's in Pakistan. Yeah.
2 Q. Beyond whatever inspiration you got from
3 your uncle and any other family members, anything else
4 that drew you to medicine?
5 A. Yeah. My father also passed away when I was
6 three and a half years old. I barely remember him.
7 And he -- he was in his mid '40s and he basically
8 passed away from meningitis. And he got an ear
9 infection and then which just went really deep and had
10 meningitis.
11 And he was admitted in the hospital. This
12 is from what my mom told he me. He was admitted in
13 the hospital, and this was also in Pakistan. He had
14 been -- physicians couldn't figure out what was going
15 on and he suffered quite a bit for several days before
16 they could even start him on antibiotics. And that
17 was such a reversible cause, I think, in my opinion,
18 that that also kind of drew me towards -- towards
19 medicine.
20 Q. That's -- from what you said, it sounds like
21 you -- you lost your father -- or at least you may
22 have lost your father because of a condition that
23 could have been effectively treated if it had been
24 addressed promptly.
25 A. Exactly. Yeah.
16
1 Q. Have -- in your own practice -- and I -- you
2 started your residency when?
3 A. 2012.
4 Q. And your first -- your first position after
5 residency was in 2015?
6 A. Yes, at Emory.
7 Q. Okay. So in the time that you've been
8 practicing in residency and since, have you ever seen
9 what you believe to be medical error in the treatment
10 of any of your patients or in the treatment of
11 patients whose care you have had any insight into?
12 A. Not that I can think of right now at the
13 moment there was a specific case or major case that
14 there was a major medical error.
15 Q. Have you ever seen medical care you felt was
16 negligent?
17 A. Negligent? Not necessarily. Maybe
18 overnight -- so I work at night; correct? So I have
19 50 percent -- I work 50 percent days and 50 percent
20 nights. So when I'm on nights, I do admit the patient
21 plus I'm also responsible for cross-coverage. So for
22 cross-coverage, for example, I would -- I can get a
23 call from nurses saying patient doesn't feel well and
24 they are getting short of breath. And I review the
25 case with the daytime physicians that's been doing all
17
1 their treating things, et cetera. For example, if I
2 see the patient was admitted with congestive heart
3 failure and they are fluid overloaded, and during the
4 daytime they have taken them off of Lasix, which we
5 give so that they can diurese that extra fluid out of
6 their body. And if it's -- and if it's stopped and
7 they're still volume overloaded, then I would start
8 the Lasix back again or give them an extra dose.
9 So stuff like that, which is -- I don't
10 know. You can call it negligence, but that would be a
11 pretty hard floor to bring that. Small stuff like
12 that, besides that, I don't -- I don't remember any
13 major, major negligence, a physician completely
14 neglected the care or a part of care of a patient and
15 then patient suffered harm because of that.
16 Q. I take it you do not believe you've ever
17 seen a patient harmed by medical negligence.
18 A. I cannot think of it right now.
19 Q. Do you -- do you believe that it is wrong to
20 hold medical providers financially responsible for the
21 harm caused by medical negligence?
22 A. I don't think so. There would have to be
23 checks and balances and consequences.
24 Q. What specifically do you think should happen
25 when medical negligence does cause serious harm to a
18
1 patient?
2 MR. LADNER: Object to form. You can
3 answer.
4 THE WITNESS: I don't know. It
5 depends upon the severity, and it could --
6 it could -- so the example could go
7 anywhere from what I described to all the
8 way up to physician who has been assigned
9 to take care of a patient, not even taking
10 care of them at all, or let's say
11 prescribing a medication which is supposed
12 to be for a different patient and then
13 doing it for the other person can cause
14 serious harm. So there's a whole range of
15 it.
16 Q. (By Mr. Holloway) Do you have any view as
17 to -- in -- let's take an example like that. Suppose
18 a doctor prescribes the wrong drug to a patient
19 negligently and causes some serious harm. Do you have
20 any view as to what kinds of specific things should
21 happen by way of holding that physician responsible?
22 MR. LADNER: Object to form. You can
23 answer.
24 THE WITNESS: I don't know -- yeah, I
25 don't know. I don't know.
19
1 Q. (By Mr. Holloway) But I take it you do not
2 have any strong view that it is unfair to hold
3 physicians financially responsible for harm they
4 caused through negligence; is that true?
5 A. Truly like I said before, if definitely
6 something has been done or has happened, there should
7 be some consequences. If they really did it and they
8 really caused it, if they really ignored, neglected.
9 Q. Setting aside what you can read in the
10 medical records here, do you have any independent
11 memory of Stefan Lane?
12 A. I actually do not. It has been so long ago
13 that I don't remember.
14 Q. Then so far as what actually happened with
15 Stefan, the only evidence you have to go on is what we
16 can all read in the medical records.
17 A. Yes.
18 Q. Now, medical providers rely on patient
19 information in the records in order to assess the
20 patient and make treatment decisions; true?
21 A. Yes.
22 Q. The accuracy of medical records is important
23 for patients' health and well-being.
24 A. Yes.
25 Q. Inaccurate information in the medical
20
1 records can lead to harm.
2 A. Yes. Yes.
3 Q. So it's important for patient health and
4 safety that the medical records contain all important
5 information the various medical providers gather;
6 true?
7 A. Yes, that's true. As much as possible.
8 More accurate and more information if possible.
9 Q. Incomplete information in the medical
10 records can lead to harm to the patient; right?
11 A. Yeah. Yep.
12 Q. So I take it, then, that when you create
13 medical records, you do your best to make them
14 accurate; yes?
15 A. Yeah, I try my best.
16 Q. Do you believe that other providers you work
17 with at Emory do the same?
18 A. I believe so, yeah. Because Emory always
19 emphasizes on that and what -- so that we can maintain
20 or increase and improve our quality of care.
21 Q. I asked you about accuracy. Let me ask you
22 about completeness. When you create medical records,
23 do you do your best to include all the important
24 information about the patient?
25 A. I try my best, yes.
21
1 Q. And I take it you believe that the other
2 people you work with at Emory Johns Creek do the same.
3 A. Yes.
4 Q. Do you know of any specific errors in the
5 medical records for Stefan Lane?
6 A. I do not, no.
7 Q. Do you know of any important information
8 that was omitted from Stefan's medical records?
9 A. I do not.
10 Q. Do you know of any reason to distrust the
11 information in Stefan's medical records?
12 A. I do not.
13 Q. I want to now go through some basic
14 principles of the medicine concerning strokes, and I'm
15 going to share my screen here. You should have a
16 little -- a black screen that says TrialPad for iPad.
17 Do you see that?
18 A. Yes.
19 Q. Okay. This is document -- these are just
20 statements that I have typed up and I want to go over
21 them in turn and see which ones we agree on.
22 Actually, let me -- let me move.
23 MR. LADNER: And I don't mean to
24 interrupt your examination, but I'll object
25 to your statements being a part of this
22
1 deposition. Subject to that objection, go
2 right ahead.
3 MR. HOLLOWAY: Sure.
4 Q. (By Mr. Holloway) Let me put this up again.
5 Let me know, is it back for you?
6 A. Yes.
7 Q. Okay. I have -- so this is a document I
8 have marked as Exhibit Chaudhry 1. Am I pronouncing
9 your name right?
10 (Plaintiffs' Exhibit 1 was marked for
11 identification.)
12 THE WITNESS: Yes.
13 Q. (By Mr. Holloway) Okay. So let's just go
14 through these quickly and see what we -- where we
15 agree and where we disagree.
16 "Stroke is a leading cause of death in the
17 United States." Do you agree?
18 A. I don't believe so.
19 Q. You do not believe so. You believe that
20 stroke is not a leading cause of death in the United
21 States; is that what you're saying?
22 A. Yeah, I don't think so, it is.
23 Q. Let me -- let me share something else, then,
24 see if I can change your mind. This is a web page
25 from the Centers for Disease Control and Prevention.
23
1 Do you see that?
2 A. Uh-huh (affirmative).
3 Q. CDC.gov.
4 A. Uh-huh (affirmative).
5 Q. And you see where it says, "Stroke is the
6 fifth leading cause of death in the United States"?
7 A. What was your statement there?
8 Q. The statement was, "Stroke is a leading
9 cause of death in the United States."
10 A. Yeah, one of them. I -- I -- I thought you
11 meant it is the leading cause.
12 Q. I see. I see. So let me go back to that.
13 So with -- here, I'll -- if I circle "a," do you
14 agree?
15 A. Yes. One of the leading causes.
16 Q. And "Stroke is a major cause of serious
17 disability for adults"; do you agree?
18 A. Yes.
19 Q. "Most strokes are ischemic strokes in which
20 a clot blocks blood flow to part of the brain"; agree?
21 A. Yes.
22 Q. "If blood flow is blocked for too long, the
23 brain tissue affected by the loss of blood will begin
24 to die"; agree?
25 A. Yes.
24
1 Q. "For ischemic strokes, we have two main
2 treatments: (a), clot-buster medication called tPA,
3 and (b) mechanical thrombectomy for large-vessel
4 occlusion." Do you agree?
5 A. Yes.
6 Q. "tPA is a medication administered through an
7 IV."
8 A. Yes.
9 Q. "Thrombectomy involves inserting a long,
10 thin catheter through the blood vessels running up
11 into the brain and using a mechanical device to pull
12 the blood clot out"; agree?
13 A. Yes.
14 Q. "tPA is simpler and faster to administer
15 than thrombectomy."
16 A. Yes.
17 Q. "tPA works for small-vessel blockages that a
18 thrombectomy is not suited for."
19 A. Yes.
20 Q. "It is important for medical providers to
21 accurately assess whether an ischemic stroke patient
22 could safely receive tPA."
23 A. Yes.
24 Q. "Inaccurate assessments may lead physicians
25 to refuse tPA to a stroke patient who needs it and
25
1 could safely receive it."
2 A. Yes.
3 Q. "Refusing tPA to a patient who needs it and
4 could safely receive it may cause the patient to die
5 or become seriously disabled."
6 A. Yes.
7 (Plaintiffs' Exhibit 2 was marked for
8 identification.)
9 Q. (By Mr. Holloway) Okay. Similar exercise
10 with a document I've marked as Exhibit Chaudhry 2.
11 "It is important for medical providers
12 responsible for stroke patients to have a basic
13 understanding of the treatments for stroke."
14 A. Yes.
15 Q. "A hospital that advertises stroke services
16 must ensure that its physicians and nurses are
17 qualified and competent to care for stroke patients."
18 A. Yes.
19 Q. "Generally, tPA can be administered only
20 with -- within four and a half hours of the onset of
21 symptoms."
22 A. Yes.
23 Q. Let me fix the typo there.
24 "For a subset of patients, tPA can be
25 administered only within three hours of the onset of
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1 neurological symptoms."
2 A. I'm not 100 percent sure, but I believe it's
3 correct.
4 Q. I'll -- to reflect that, I'll put a
5 checkmark with a question mark; is that fair?
6 A. Yeah.
7 Q. Okay. "The time just before neurological
8 symptoms began is referred to as the 'last known well'
9 or 'last known normal.'"
10 A. The time just before neurological symptoms
11 began. So it depends if they -- so that's not always
12 true. So let's say if I already have difficulty
13 speaking, and then six hours later, I have right upper
14 extremity weakness, so right before I developed right
15 upper extremity weakness was not my last known normal.
16 Q. I see what you're saying.
17 A. Yeah.
18 Q. Is it -- is it correct to say the time just
19 before the first --
20 A. The time --
21 Q. -- neurological symptoms began is referred
22 to as the last known well or last known normal?
23 A. Yeah. Yeah, I think we can say that.
24 Q. Okay. Okay. "The decision to give tPA or
25 refuse it depends in part on the time of the last
27
1 known well."
2 A. Yes.
3 Q. "Accurate identification of the last known
4 well is crucial to patient safety."
5 A. Yes.
6 Q. "Misidentification of the last known well
7 may lead physicians to refuse tPA to a patient who
8 needs it and can safely receive it."
9 A. Yes.
10 Q. "Misidentification of the last known well
11 may lead to death or serious disability for a patient
12 who would have recovered well after receiving tPA."
13 A. True.
14 (Plaintiffs' Exhibit 3 was marked for
15 identification.)
16 Q. (By Mr. Holloway) Next document, similar
17 thing. I've marked this as Exhibit Chaudhry 3. At
18 the top, "An ischemic stroke is a blockage of blood
19 flow to part of the brain where the blockage lasts
20 long enough to cause some brain tissue to die."
21 A. Where the blockage if lasts long enough?
22 Q. "Where the blockage lasts long enough to
23 cause some brain tissue to die."
24 A. Sure. Yes.
25 Q. "A transient ischemic attack is a temporary
28
1 blockage of blood flow to the brain."
2 A. Yes.
3 Q. "While a TIA is in progress, the symptoms of
4 the TIA are the same or similar to the symptoms of an
5 ischemic stroke."
6 A. Yes.
7 Q. "After a TIA ends, the symptoms end."
8 A. Yes.
9 Q. "In a full-blown ischemic stroke, the
10 blockage lasts long enough to cause permanent
11 injuries."
12 A. Yes.
13 Q. "A TIA presents the risk of a full-blown
14 stroke."
15 A. Yes.
16 (Plaintiffs' Exhibit 4 was marked for
17 identification.)
18 Q. (By Mr. Holloway) Okay. If the -- this is
19 a page that's marked as Exhibit Chaudhry 4.
20 A. Okay.
21 Q. Similar thing. You basically just told me
22 this, but to set the context for this page, "After a
23 TIA -- after a TIA ends, the patient is at risk for a
24 full-blown ischemic stroke"; yes?
25 A. Yes.
29
1 Q. "After a TIA ends, if the patient has a
2 later stroke, clot-buster tPA may be given to treat
3 the stroke."
4 A. Yes.
5 Q. "After a TIA ends with the blockage cleared
6 and no further neurological symptoms, the window for
7 tPA therapy resets."
8 A. Yes.
9 Q. There's a corollary. "After a TIA ends, the
10 time of the last known well resets."
11 A. Yes.
12 Q. "If the patient has a later stroke, the time
13 of the last known well will be after the TIA ended
14 before the new stroke symptoms began."
15 A. Yes.
16 Q. "Accurately identifying the time of the last
17 known well is crucial to patient safety."
18 A. Yes.
19 Q. "If an emergency room patient comes in with
20 a TIA, after the TIA ends, the hospital can either,
21 (a), discharge the patient with instructions to return
22 in the event of later stroke symptoms, or (b), admit
23 the patient to the hospital for observation."
24 A. Yes.
25 Q. "Patients are admitted for observation to
30
1 ensure that if the patient suffers a full-blown
2 stroke, it can be identified and treated promptly."
3 A. Yes.
4 Q. "If a hospital admits a patient for
5 observation after a TIA, the hospital must monitor the
6 patient's neurological status."
7 A. True.
8 Q. "If the admitted patient has a later stroke
9 while in the hospital, it is crucial that the
10 physicians be able to accurately identify the
11 patient's last known well."
12 A. True.
13 Q. "Misidentification of the last known well
14 may cause the physician to refuse tPA where the
15 patient needs it and can safely receive it causing
16 that patient to suffer death or serious disability."
17 A. True.
18 Q. "Accurate assessment of the patient's
19 neurological status while in the hospital is crucial
20 to identify the patient's last known well in the event
21 of a later stroke."
22 A. True.
23 Q. "A hospital that treats stroke patients must
24 ensure that its staff are competent to perform
25 neurological assessments that allow accurate
31
1 identification of a patient's last known well."
2 A. True.
3 Q. "It is crucial that the physicians and/or
4 nurses responsible for the patient do, in fact,
5 perform neurological assessments that allow accurate
6 identification of a patient's last known well."
7 A. True.
8 (Plaintiffs' Exhibit 5 was marked for
9 identification.)
10 Q. (By Mr. Holloway) A similar thing here.
11 I've marked this Exhibit Chaudhry 5. Up at the top,
12 "When a hospital admits a patient for observation
13 after a TIA, the hospital staff must monitor the
14 patient frequently enough that if the patient suffers
15 a stroke later, the physicians can identify and treat
16 the stroke promptly."
17 A. Yeah, as much as possible.
18 Q. So do you believe the statement is true?
19 A. Yes.
20 Q. I think we covered this earlier, but to
21 confirm, "Generally, the window for tPA is four and a
22 half hours from the patient's last known well."
23 A. Yes.
24 Q. And "For some patients, the window for tPA
25 is three hours from the patient's last known well." I
32
1 think --
2 A. Yes. I think it's the same thing.
3 Q. True with a question mark.
4 MR. LADNER: We already did this?
5 MR. HOLLOWAY: Those two, we did.
6 I've repeated them here for context.
7 Q. (By Mr. Holloway) "From the time hospital
8 staff learns a patient is suffering stroke symptoms,
9 it can take more than half an hour to begin
10 administering tPA."
11 A. It can, yes.
12 (Plaintiffs' Exhibit 6 was marked for
13 identification.)
14 Q. (By Mr. Holloway) So now I want to show you
15 what I've marked as Exhibit Chaudhry 6. This is --
16 again, this is a document I have created. This is
17 a -- this is a hypothetical scenario --
18 A. Okay.
19 Q. -- to work through the timing. And I want
20 to make sure that you and I agree on the implications
21 of the timing. So -- but I've -- and you can -- I've
22 put a little -- to show that this is a hypothetical, I
23 put a face of someone who is not Stefan Lane here.
24 A. Uh-huh (affirmative).
25 Q. Okay. So on this Exhibit Chaudhry 6, let's
33
1 say at midnight a patient arrives with TIA or stroke
2 symptoms; okay?
3 A. Uh-huh (affirmative).
4 Q. And then let's say there's an order for
5 neurological monitoring every two hours and it's
6 entered, say, roughly half an hour after the patient
7 arrives in the ER. You with me?
8 A. Uh-huh (affirmative).
9 MR. LADNER: Dan, can I have a
10 continuing objection to this exhibit and
11 any questions related to it as well?
12 MR. HOLLOWAY: Sure.
13 MR. LADNER: Thank you.
14 Q. (By Mr. Holloway) So -- so in our
15 hypothetical, that order is entered, and then half an
16 hour later, the first neurological assessment is done
17 and it finds that the symptoms have resolved and the
18 patient is neurologically normal. You with me?
19 A. Uh-huh (affirmative).
20 Q. So in that -- in that scenario, the window
21 for tPA is reset. Do you agree?
22 A. Yes.
23 Q. Okay. Now, to continue our hypothetical,
24 let's say about an hour, 45 minutes later, the
25 patient -- we'll call her Nancy to make sure that this
34
1 is a hypothetical. Nancy's stroke symptoms resume
2 around 1:45.
3 A. Uh-huh (affirmative).
4 Q. Okay? And then because the order for
5 neurological monitoring has been every two hours, and
6 because the nurses are on their -- they're acting
7 diligently, two hours after the first assessment at
8 1:00 -- so the first assessment was 1:00. Two hours
9 later is 3:00, and in our hypothetical, an assessment
10 is done here; okay?
11 A. Uh-huh (affirmative).
12 Q. And at that assessment, TIA stroke symptoms
13 are identified.
14 A. Uh-huh (affirmative).
15 Q. Do you agree that in that situation the
16 physicians would consider tPA?
17 A. Yeah, if they confirm from what they have
18 established before and if they have confirmed and
19 established at that moment.
20 Q. Okay. So in that situation with the
21 physicians considering tPA, they are going to try to
22 figure out when was the last known well; true?
23 A. True.
24 Q. So they -- the physicians will look back to
25 the immediately prior neurological assessment at 1:00.
35
1 A. When -- when was the patient admitted?
2 Q. So the -- in our hypothetical, Nancy came in
3 around midnight.
4 A. Uh-huh (affirmative).
5 Q. An order for monitoring every two hours was
6 entered shortly thereafter.
7 A. Uh-huh (affirmative).
8 Q. An assessment was done at 1:00 a.m. --
9 A. By who?
10 Q. -- that showed her symptoms had resolved and
11 she was neurologically normal.
12 A. Done by who?
13 Q. Let's say done by -- well, to decide how to
14 fill out the hypothetical, what is the significance of
15 who it was done by?
16 A. That would determine if it was a complete
17 assessment or not.
18 Q. Okay. So let's -- first of all, for
19 purposes of this discussion, let's say it was done
20 by -- the first assessment was done by an ER
21 physician.
22 A. Okay.
23 Q. So if that's -- if this is -- if the first
24 assessment -- let's say both of these assessments are
25 done by an ER physician.
36
1 A. Okay.
2 Q. In that case, would you agree that the last
3 known well would be the time of the first assessment?
4 A. True.
5 Q. Okay. So if we're here at 3:00 a.m., we're
6 looking back at the last known well, which was two
7 hours ago; right?
8 A. Yes. Yeah, 1:00 a.m. and 3:00 a.m.
9 Q. And that would mean that for a patient for
10 whom the tPA window is four and a half hours, the tPA
11 window is still open for another two and a half hours;
12 right?
13 A. Right.
14 Q. Plenty of time to assess the patient and, if
15 appropriate, administer tPA; right?
16 A. Yes.
17 Q. And even if it's a patient with a three-hour
18 tPA window, in this scenario, the window is still open
19 for another hour; right?
20 A. Yes.
21 Q. Would you -- would you agree that an hour is
22 probably enough time to administer tPA if appropriate?
23 A. It can be, yeah, but not necessarily.
24 Q. Right. The -- leaving just a one-hour
25 window, that's cutting it kind of tight for this
37
1 patient; right?
2 A. Yeah. Yeah.
3 Q. Okay.
4 A. So in this scenario, tracking the complete
5 neurologic assessment, doing that more frequently
6 would be beneficial.
7 Q. Right.
8 A. Yeah.
9 Q. For -- so if we knew back when Nancy, our
10 hypothetical patient -- back when she comes into the
11 ER, if we knew that she was the kind of patient for
12 whom the tPA window would be four and a half hours,
13 then this scenario is okay for her.
14 A. Yes.
15 Q. But if we knew that it was a patient for
16 whom the window was three hours, this is -- this
17 scenario is dicey and is putting her at risk.
18 A. Yeah.
19 Q. Now I'm going to go to a different scenario.
20 I've marked this as Exhibit Chaudhry 7. So here, same
21 deal. Our hypothetical patient Nancy comes in at
22 midnight. Only this time, the order for neurological
23 monitoring is every four hours rather than every two
24 hours.
25 (Plaintiffs' Exhibit 7 was marked for
38
1 identification.)
2 THE WITNESS: Uh-huh (affirmative).
3 MR. LADNER: Dan, just the same
4 continuing objection.
5 MR. HOLLOWAY: Yes.
6 Q. (By Mr. Holloway) And then at -- at the
7 first assessment at 1:00 a.m., as in the previous
8 scenario, symptoms resolved, the assessment is done by
9 an ER physician.
10 A. Uh-huh (affirmative).
11 Q. Symptoms resolved, she's neurologically
12 normal, and we agree that the clot -- that the tPA
13 window resets; right?
14 A. Uh-huh (affirmative).
15 Q. The court reporter needs you to say yes or
16 no.
17 A. Yes.
18 Q. They can -- the reporter can take down
19 the --
20 A. Yeah, I know.
21 Q. And it's hard.
22 A. Yeah.
23 Q. Okay. So as in the previous scenario, about
24 an hour and 45 minutes later, Nancy's symptoms return;
25 okay?
39
1 A. When?
2 Q. At -- here. So about an hour 45 minutes
3 after the first neuro assessment.
4 A. How did we establish that?
5 Q. This is a hypothetical. I'm just creating a
6 scenario so that we can talk through the issues.
7 A. Okay.
8 Q. You with me?
9 A. Yes.
10 Q. All right. So now this time, because the
11 order for neurological monitoring was every four
12 hours, the assessment is -- instead of the assessment
13 being done at 3:00 a.m., it's done at 5:00 a.m.
14 A. Uh-huh (affirmative).
15 Q. And here, again, the assessment shows stroke
16 symptoms. You with me?
17 A. Who did the second assessment?
18 Q. Let's say --
19 A. Is this in the ER?
20 Q. Yeah. Let's say it's the same -- the same
21 ER physician.
22 A. Okay. Yes.
23 Q. All right. So just as in the first
24 scenario, here, again, the physician is going to at
25 least consider tPA; right?
40
1 A. Yeah.
2 Q. And in considering tPA, the physician is
3 going to have to look back to the last known well;
4 right?
5 A. Which started when?
6 Q. Well, do we -- I think we agreed that the
7 last known well would be the time of the first
8 neurological assessment.
9 A. No, we didn't.
10 Q. Okay. So let's backtrack. Let's go back to
11 this.
12 A. We -- what was it called? Chaudhry
13 exhibits, in those, we established that the patient's
14 last known well is right before their symptoms start
15 for a new stroke. You don't remember that? I don't
16 know what page it was.
17 Q. Sure. Let me go -- let me go find it.
18 So it was Exhibit Chaudhry 4, and --
19 A. I think No. 3.
20 Q. Yeah. So we agreed that after a TIA ends
21 with the blockage cleared and no further neurological
22 symptoms, the window for tPA therapy resets. Do you
23 still agree?
24 A. Yeah.
25 Q. And the corollary is after a TIA ends, the
41
1 time of the last known well resets. Do you still
2 agree?
3 A. Yes.
4 Q. Okay. Let's go back to --
5 A. Can I read the next one?
6 Q. Yeah. Yeah. Let me make it bigger. And
7 I'll highlight the next one as well.
8 A. "If a patient has a later stroke, the time
9 of last known well will be after the TIA ended, before
10 the new stroke symptoms began." Right.
11 Q. You still agree?
12 A. Yeah.
13 Q. Okay. So going back to our hypothetical in
14 Exhibit Chaudhry 7 --
15 A. Uh-huh (affirmative).
16 Q. -- and so for now, at least, we're -- we're
17 saying that these two neurological assessments were
18 both done by an ER physician, by the -- we'll say by
19 the same ER physician; okay?
20 A. Yeah.
21 Q. So in that setting, in this scenario, the ER
22 physician has done an assessment an hour after Nancy
23 comes into the ER, and the ER physician finds that the
24 symptoms have resolved. Nancy is neurologically
25 normal. So in that scenario, we agree, do we not,
42
1 that the tPA window has reset?
2 A. Yes.
3 Q. Okay. And then fast-forward four hours. At
4 the second --
5 A. What happened after 1:30? How can you skip
6 that?
7 Q. I don't -- I don't mean to skip that. We've
8 already gone over this. So in this hypothetical --
9 A. Uh-huh (affirmative).
10 Q. -- the first neurological assessment is at
11 1:00.
12 A. Uh-huh (affirmative).
13 Q. Then at 1:30, Nancy starts experiencing
14 stroke symptoms again; okay?
15 A. Who had established that?
16 Q. Let's -- let's assume that that's what
17 happens. Just -- you know, so it's not -- it's not
18 that a nurse walked in and saw it happening.
19 A. Uh-huh (affirmative).
20 Q. But we, looking down on this situation from
21 the sky, as if we're reading it in a book --
22 A. Sure.
23 Q. -- we know that she is, in fact, suffering
24 stroke symptoms.
25 A. All right. Okay.
43
1 Q. All right. So then in the intervening time,
2 nobody does another neurological assessment, they
3 don't stumble over it by chance, but at -- at 5:00,
4 the doctor comes in, you know, right on the spot,
5 exactly four hours after the first assessment to do
6 another assessment; okay?
7 A. Okay.
8 Q. And the doctor finds the stroke symptoms are
9 present so he's going to consider whether tPA is a
10 possible treatment; agree?
11 A. Yes.
12 Q. Okay. So in that situation, he looks back
13 to the last known well, which is the time of the first
14 assessment back at 1:00 a.m.; true?
15 A. Yes. True.
16 Q. But now the problem is four hours of the tPA
17 window has already been used up; right?
18 A. Uh-huh (affirmative).
19 Q. So for a patient with a four-and-a-half-hour
20 window, that window is now going to close in
21 30 minutes; right?
22 A. True.
23 Q. For that patient, this is a risky situation
24 because there's a good chance that the tPA cannot be
25 administered within 30 minutes.
44
1 A. True.
2 Q. Okay. And what's worse is that if the
3 patient happens to be someone for whom the tPA window
4 is only three hours, she's just completely out of
5 luck; right?
6 A. Uh-huh (affirmative).
7 Q. That's a yes?
8 A. Yes. True. Yes.
9 Q. So the four-hour monitoring regimen is bad
10 for the four-and-a-half-hour-window patients, and it's
11 terrible for the three-hour-window patients; agree?
12 A. True. Yes.
13 Q. Okay. Now let me go back to -- I'll stay --
14 I'll just stay on this exhibit for this discussion.
15 You asked earlier in our -- in our scenario
16 who did the neurological assessments. You asked that;
17 right?
18 A. Yes.
19 Q. And we said for -- I said for -- for the
20 moment let's -- let's say the assessment was done by
21 an ER physician. Now I want to change that. Let's
22 say this neurological assessment at 1:00 a.m. -- so
23 we're still on Exhibit Chaudhry 7 -- for this -- if
24 this assessment at 1:00 a.m., neuro assessment one, if
25 that is done by a nurse, how does that change the
45
1 scenario in your mind?
2 A. So we have to first establish what the neuro
3 assessment is. Is it the same neuro assessment that
4 the ER physician does or what I do or what a
5 neurologist does, same thing as what the nurses do?
6 Q. How would you answer that question?
7 A. That it's not.
8 Q. Okay. So at Emory --
9 A. Uh-huh (affirmative).
10 Q. And now I'm not -- I'm no longer talking
11 hypothetically. I'm asking about the actual facts at
12 Emory Johns Creek Hospital.
13 Does Emory ensure that the nurses they hire
14 and assign responsibility to care for stroke patients
15 are competent and diligent to perform a neurological
16 assessment that would allow physicians to accurately
17 identify the time of the last known well?
18 A. Yes, I believe so.
19 Q. Just to put a point on it, if Emory is
20 hiring nurses who cannot do that job, then Emory is
21 dooming some number of their stroke patients to death
22 or serious disability.
23 MR. LADNER: Object to form.
24 Q. (By Mr. Holloway) Right?
25 A. If they are not doing that, they would not
46
1 get approved to be a stroke center.
2 Q. I -- I understand what you're saying.
3 A. Yeah.
4 Q. But I want to -- I want to make sure that
5 you agree with me on the takeaway point that I just
6 made. Let me -- let me restate it a little bit.
7 We've already agreed that in treating a
8 stroke patient, it is crucially important that
9 physicians be able to accurately identify the time of
10 the last known well; yes?
11 A. Yes.
12 Q. And at Emory, as I assume in most hospitals,
13 the hospital administration and the physicians rely on
14 nurses to perform regular neurological assessments of
15 patients.
16 A. Yes, they do.
17 Q. Okay. If Emory is hiring nurses who cannot
18 do a neurological assessment that would let you
19 correctly identify the last known well, that is a huge
20 problem for the patient.
21 MR. LADNER: Object to form.
22 Q. (By Mr. Holloway) You can still answer.
23 A. What -- what -- what can I say about that?
24 You can say that any -- about anything, any job, any
25 type of profession. If a person is not -- is hired
47
1 to -- hired as an environmental services person and
2 they are not doing their job, then -- we established
3 that when we had the conversation about negligence, et
4 cetera.
5 Q. I -- right, but let me -- let me go back to
6 the specific question that I asked a second ago
7 because I'm not asking about -- I take your -- I
8 understand your point.
9 A. Yeah.
10 Q. I think it's a fair point, but I want to
11 make sure that I've got a specific answer to the
12 specific question I was asking.
13 So specifically, in talking about stroke
14 patients, if it were the case that Emory was hiring
15 nurses who cannot do neurological assessments that
16 would allow you to accurately identify the last known
17 well, that would create huge problems for Emory's
18 patients.
19 MR. LADNER: Object to form.
20 Q. (By Mr. Holloway) True?
21 A. What -- why are we saying that? The
22 nurses -- it's not that they cannot or they can
23 perform the exam. They're doing -- they are basically
24 following the orders of what they are supposed to
25 follow. And the -- the test, the exam that they
48
1 are -- that -- whatever orders they have been given,
2 whatever their protocol is, they follow that. And
3 their assessment is not what the assessment of a
4 neurologist would be. That's -- that's the big
5 difference that you need to understand. You're using
6 neurological assessment. What assessment? Whose
7 assessment? What is the details of that assessment?
8 So -- and the nurses that -- the assessments
9 that the nurses do is not to establish the patient's
10 last known normal, which is part of the protocol of
11 the TIA patients that get admitted at Emory, at all
12 Emory facilities.
13 Q. Okay. I hear all that, and I still want to
14 come back to the question I was asking. But let me --
15 let me -- let me take a step farther back.
16 If -- if Emory admits a patient for
17 observation after they've had a TIA, somebody had
18 better be monitoring neurological status in order to
19 establish last known well; true?
20 A. I -- I -- it's very difficult to answer
21 that.
22 Q. What's -- I'll try to make it easier if you
23 tell me what the difficulty is.
24 A. I think the best -- in the best-case
25 scenario, just like the hypothetical example that you
49
1 were giving, in the best-case scenario, what ideally
2 should be done is that I should be either present in
3 the room almost all the time or do a neurological
4 assessment every hour of that patient myself to
5 establish the last known normal and do a complete
6 neurological assessment.
7 Q. I -- one of the things I think you just said
8 or implied at least that if -- if you were to do a
9 neurological assessment, your assessment would be good
10 enough to establish the last known well.
11 A. Yeah, if I do a complete -- when I do a
12 complete neurological exam, yes.
13 Q. All right. Let me go back to what I was
14 asking. Is it true that if Emory admits a patient for
15 observation after a TIA, somebody had better be doing
16 neurological assessments that allow correct
17 identification of last known well?
18 MR. LADNER: Object to form. You can
19 answer.
20 THE WITNESS: In an ideal situation,
21 yes.
22 Q. (By Mr. Holloway) Do you believe -- let's
23 use the phrase "standard of care." Do you believe the
24 standard of care allows Emory to admit a patient for
25 observation after a TIA and not to do neurological
50
1 assessments that allow correct identification of last
2 known well?
3 A. What I believe what happens and what --
4 what's being done at Emory is the standard of care.
5 Q. That was not the question. The question is:
6 Do you believe the standard of care allows Emory to
7 admit a patient for observation after a TIA and choose
8 not to do neurological evaluation that allows correct
9 identification of last known well?
10 A. I don't know. Can you repeat the question
11 again?
12 Q. Yes. Do you believe the standard of care
13 allows Emory to admit a patient for observation after
14 a TIA and fail to do neurological assessments that
15 allow correct identification of last known well?
16 A. So I specifically don't know all the details
17 about the standard of care, but I do believe what
18 happens at Emory is the standard of care.
19 Q. I know -- I know that's the position that
20 you take, but that wasn't the question. Let me ask it
21 again.
22 Do you believe the standard of care allows
23 Emory to admit a patient for observation after a TIA
24 and fail to do neurological assessments that allow
25 correct identification of the patient's last known
51
1 well?
2 MR. LADNER: Object to form.
3 THE WITNESS: I just said I don't know
4 the details about the standard of care so
5 how can I answer the question in yes or no?
6 Q. (By Mr. Holloway) Okay. I --
7 A. Right?
8 Q. I take --
9 A. You're asking -- you're asking it again, and
10 what I do believe wholeheartedly that Emory does
11 follow the standard of care.
12 Q. Yeah, well --
13 MR. HOLLOWAY: Objection,
14 nonresponsive.
15 Q. (By Mr. Holloway) So I think -- I take your
16 point. I think you have answered the question. What
17 you're saying is you don't know one way or the other
18 whether the standard of care requires neurological
19 assessments that allow correct identification of the
20 last known well.
21 A. Yeah, I do not know.
22 Q. Nobody at Emory has told you that patients
23 need to be assessed adequately to identify the last
24 known well.
25 A. We just follow the Emory protocols which
52
1 basically encompasses all of this, and the best way to
2 treat a TIA patient under observation, and we do
3 believe when we place these orders, they are all based
4 off of extensive amount of research and they do follow
5 the standard of care. And whatever is encompassed in
6 that order set is what it is.
7 MR. HOLLOWAY: Objection,
8 nonresponsive.
9 Q. (By Mr. Holloway) The question is: Nobody
10 at Emory has told you that it is necessary to assess
11 neurological status adequately to correctly identify
12 last known well.
13 MR. LADNER: Object to form. You can
14 answer.
15 THE WITNESS: Same response what I
16 said before.
17 MR. HOLLOWAY: Well, objection,
18 nonresponsive.
19 Q. (By Mr. Holloway) Has anybody at Emory told
20 you that you must ensure neurological assessments are
21 being done sufficient to identify last known well?
22 MR. LADNER: Object to form, asked and
23 answered. You can answer it again.
24 THE WITNESS: Same thing. I don't
25 have anything new to add. You can continue
53
1 asking the same thing. I mean...
2 Q. (By Mr. Holloway) Okay. What has Emory
3 told you about the need or lack of need for
4 neurological assessments adequate to identify last
5 known well?
6 A. Whatever is in there, in the medical record,
7 in the orders that I have placed according to the
8 ischemic stroke or TIA order set, that is what they
9 have, you can say, quote/unquote, told me.
10 Q. Well, what has Emory told you about what
11 kind of neurological assessment is adequate to
12 correctly identify last known well?
13 A. So that would be -- that would be determined
14 by a complete neurological examination, whenever it's
15 done in the hospital however frequently it's done or
16 it can be done. So that would determine it.
17 Q. Are you saying that's what Emory has told
18 you?
19 A. We can -- yeah, we can say that. Yes.
20 Q. Emory has told you that --
21 MR. LADNER: He wasn't finished with
22 his answer.
23 Q. (By Mr. Holloway) Oh, I'm sorry.
24 A. And also based off of our training and our
25 learning and our practice, all of that. See, for
54
1 example, if a neurologist comes and examines the
2 patient and he tells me that he has examined the
3 patient completely and he does not find any deficits
4 in that patient, then I would -- then I would say
5 that's that patient's last known normal.
6 Or if an ER physician says that to me or if
7 I go and evaluate the patient and establish that
8 myself, so that would be the last known normal for me
9 if I don't find any -- any deficits at all.
10 Q. I want to make sure I understand what you're
11 saying. Let me -- so here's the question, and I'll
12 read this after I type it.
13 My question is: Who can do a neurological
14 assessment adequate to identify the patient's last
15 known well? And I think you've already told me a
16 neurologist can do -- can do that; right?
17 A. Uh-huh (affirmative).
18 Q. I think you've said an ER physician can do
19 that; is that right?
20 A. Yes.
21 Q. I think you said that you can do that.
22 A. Yes.
23 Q. Is it fair to say hospitalist?
24 A. Sure.
25 Q. Okay. So the big question obviously is:
55
1 What about nurses? Can -- will a nurse's neurological
2 assessment be adequate -- at Emory Johns Creek
3 Hospital be adequate to identify the patient's last
4 known well?
5 A. If they do the same exam as the neurologist
6 does.
7 Q. Well, do the -- do the ER physicians and the
8 hospitalists do the same exam as the neurologist does?
9 A. Yes. It's adequate enough to establish
10 that, the last known normal, but obviously the
11 neurologist's exam is more detailed.
12 Q. Okay. So -- so the nurses do not have to do
13 the same exam that the neurologist does for -- for
14 their assessment to be adequate; right?
15 A. Yeah, their exam is not -- or assessment is
16 nowhere near as detailed as a neurologist's exam.
17 Q. Okay. But you believe that the ER physician
18 and hospitalist's assessment is still adequate to
19 identify the patient's last known well.
20 A. Yes.
21 Q. And so if the nurses do the same exam that
22 an ER physician or hospitalist would do, then they
23 would be -- that assessment would also be adequate;
24 right?
25 A. I believe so, yeah.
56
1 MR. LADNER: Dan, we've been going
2 about an hour and a half, when you get to a
3 breaking point.
4 MR. HOLLOWAY: Well, yeah -- okay.
5 I'll keep that in mind.
6 Q. (By Mr. Holloway) So -- well, so the
7 question is: At Emory Johns Creek Hospital, do the
8 nurses do the same exam as an ER physician or
9 hospitalist?
10 MR. LADNER: Object to form.
11 THE WITNESS: In doing their
12 assessment?
13 Q. (By Mr. Holloway) Yeah.
14 A. No, they don't.
15 Q. Okay. So, in fact, a nurse's -- I'm going
16 to try to summarize your testimony and I'm going to
17 write it down to make sure I've got the gist
18 accurately.
19 In fact, a nurse's neuro assessment at Emory
20 Johns Creek Hospital is not adequate to identify the
21 patient's last known well.
22 A. Normal is right. That would be better.
23 Yes.
24 Q. You prefer last known normal?
25 A. Yeah.
57
1 Q. Okay. I'll change it up above too. So this
2 is your testimony. In fact, a nurse's neurological
3 assessment at Emory Johns Creek Hospital is not
4 adequate to identify the patient's last known normal.
5 MR. LADNER: Object to form.
6 THE WITNESS: True.
7 MR. LADNER: Go ahead.
8 THE WITNESS: True.
9 Q. (By Mr. Holloway) Okay. Before we go
10 farther here, your -- you are firm on this point; is
11 that right?
12 MR. LADNER: Object to form.
13 THE WITNESS: Yeah.
14 Q. (By Mr. Holloway) I'm going to --
15 A. I mean, they can give us their opinion, and
16 then I would quickly go and evaluate the patient in a
17 scenario and then establish it myself, so...
18 Q. Okay. I'm not sure I -- I got that. You're
19 saying --
20 A. So if a nurse calls a neurologist or they're
21 in the emergency department, then they would -- let's
22 say if a patient is in the emergency department and
23 they are having some neurological symptoms. And then
24 they call the physician or provider in the ER and they
25 go examine the patient and they don't find anything
58
1 abnormal with that patient. That would establish the
2 last known normal of that patient.
3 Q. Well, that's -- that's not how it works in
4 practice, is it? Let me ask that differently. How
5 often in your experience does a nurse do a regularly
6 scheduled neuro assessment and then get on the phone
7 and tell a neurologist, Hey, come down and do this --
8 I just did an assessment. Come do your own assessment
9 because I'm not competent to identify last known well.
10 MR. LADNER: Object to form.
11 Q. (By Mr. Holloway) How often does that
12 happen?
13 A. So if they see a new major neurologic
14 change, then they will definitely call and say, Hey, I
15 think the patient is having this. Can you come and
16 take a look. Therefore, they do not specifically go
17 and type in a neurological exam, the whole detailed
18 exam.
19 Q. Okay. This testimony began a moment ago
20 that, in fact, a nurse's assessment at Emory Johns
21 Creek Hospital is not adequate to identify the
22 patient's last known normal.
23 First of all, do you want to walk that back
24 or are you solid on that point?
25 MR. LADNER: Object to form. You can
59
1 answer it.
2 THE WITNESS: No, I think I do believe
3 that. The neuro exam that the nurses
4 follow every four hours based off of the
5 order set that we place and request them to
6 do every four hours is not to establish the
7 patient's last known normal.
8 Q. (By Mr. Holloway) And did you know that in
9 December 2017 when Stefan Lane came under your care?
10 A. Based off of the medical records, yeah.
11 Like I said, I don't specifically remember them
12 personally because it has been so long ago. It's been
13 quite some time and...
14 Q. Okay. So you see the problem that sets up
15 for Stefan Lane and other patients like him; right?
16 A. Yeah. Yeah, I do. Do you want to go back
17 to your -- what was it called? Chaudhry 1?
18 Q. I can in a moment, but I've got a couple of
19 follow-ups here.
20 So based on what you're saying --
21 A. I think it will really help us all if you
22 did go back to that.
23 MR. LADNER: Dan -- Dan, let's take a
24 break. Let's take five minutes.
25 MR. HOLLOWAY: No. No.
60
1 MR. LADNER: No, you said we can take
2 a break whenever we need to. There's not a
3 question pending. I need a break. It's
4 been almost two hours.
5 MR. HOLLOWAY: All right.
6 MR. LADNER: We'll take a break.
7 MR. HOLLOWAY: We can do that, but the
8 first question when we come back is going
9 to be: Dr. Chaudhry, did you speak to your
10 lawyer about the substance of this
11 deposition during the break?
12 MR. LADNER: He's not going to answer
13 that question. You can ask him whatever
14 you want. It's been almost two hours. I
15 asked for a break 15 minutes ago. We're
16 taking a break. He's not going to answer
17 that question.
18 MR. HOLLOWAY: That's fine. I am -- I
19 am asking do not talk about the substance
20 of the deposition during the break. We can
21 go off the record.
22 (A recess was taken.)
23 Q. (By Mr. Holloway) Dr. Chaudhry, over the
24 break, did you talk to your lawyer about the substance
25 of this deposition?
61
1 MR. LADNER: Object to the question.
2 I'll instruct the witness not to answer.
3 Dan, you really think it's
4 appropriate? In Georgia, we have an
5 attorney-client privilege. You are not
6 allowed to inquire into anything we
7 discussed. Do you think that's an
8 appropriate question?
9 MR. HOLLOWAY: I'm avoiding colloquies
10 here.
11 Q. (By Mr. Holloway) Dr. Chaudhry, you're
12 going to follow your lawyer's instruction not to
13 answer?
14 A. Yes.
15 Q. Okay. Before the break, we were talking
16 about -- well, now that we've had the break, do you
17 need to revise any of your -- the testimony you've
18 already given?
19 A. No.
20 Q. Okay. So before the break, we were talking
21 about your testimony that a neurological assessment
22 done by nurses is not adequate to identify the
23 patient's last known well. Do you recall that
24 discussion?
25 A. Yes.
62
1 Q. Okay. Your testimony here today that the
2 nurse's assessment is not adequate to identify last
3 known well, did you believe that to be true in
4 December 2017 When Stefan Lane came under your care?
5 A. Yes.
6 Q. So your testimony is that you assigned the
7 task of conducting neurological assessments for Stefan
8 Lane to nurses you believed were not capable of doing
9 an assessment that would let you identify Stefan's
10 last known well?
11 MR. LADNER: Object to form, misstates
12 his testimony.
13 Q. (By Mr. Holloway) Do I have that right?
14 MR. HOLLOWAY: No speaking objections,
15 please.
16 MR. LADNER: Object to form, misstates
17 his testimony.
18 THE WITNESS: Remember we established
19 that the nurses can do the same exam as
20 neurologists do?
21 Q. (By Mr. Holloway) Are you saying now that
22 as a matter of fact, nurses can, after all, do
23 neurological assessments adequate to identify last
24 known well?
25 MR. LADNER: Object to form.
63
1 THE WITNESS: Yeah, if they're trained
2 like them and if they do the same exam --
3 almost the same exam as a neurologist does
4 or a physician does. But their
5 neurological assessment per the protocol
6 does not establish the last known normal.
7 Q. (By Mr. Holloway) All right. I want to
8 make sure I understand. I think you're saying, yes,
9 in theory a nurse could do a neurological assessment
10 adequate to identify last known well, but in practice,
11 at Emory, they don't.
12 A. Yes.
13 Q. That's your testimony.
14 A. Yes.
15 Q. So as a practical matter, when nurses
16 operate according to normal protocols and procedures
17 at Emory, their neurological assessments will not let
18 you identify last known well.
19 A. True.
20 Q. And you knew that in December 2017 when
21 Stefan Lane came under your care.
22 A. True.
23 Q. And if you knew that, surely you're not the
24 only physician at Emory who knew that, were you?
25 A. Of course.
64
1 Q. That was generally known by the physicians
2 treating stroke patients --
3 A. TIA.
4 Q. -- at Emory.
5 Post-TIA patients.
6 A. Yes.
7 Q. Okay. Is that phrase "post-TIA," does that
8 make a difference?
9 A. Yeah.
10 Q. Okay. So it was generally known at Emory
11 that -- by physicians treating post-TIA patients that
12 the neurological assessments routinely done by nurses
13 were not adequate to allow physicians to identify last
14 known well.
15 A. True.
16 Q. For treating post-TIA patients, in this
17 case, you know that you ordered neurological
18 assessments to be performed by nurses; right?
19 A. The Q4 hour nurses' assessment, neurological
20 assessment, yes.
21 Q. When -- when treating a post-TIA patient who
22 has been admitted for observation, is it customary at
23 Emory to assign the job of routine neurological
24 assessments to the nurses?
25 A. Yes. Per the protocol, the Q4 hour checks.
65
1 Q. So the routine at Emory in December 2017 --
2 well, first of all, Stefan, of course, was in the
3 hospital in December 2017. Has the -- the protocol or
4 the customary procedure changed from December 2017
5 until now?
6 A. I don't believe so.
7 Q. So then and now, the practice at one of
8 Emory's primary stroke centers was to assign the task
9 of routine neurological assessments for a post-TIA
10 patient to nurses who would not perform assessments
11 adequate to identify the patient's last known well.
12 A. Yeah, true. For a post-TIA patient who was
13 being observed in the hospital.
14 Q. We started to get into this before the
15 break, but you see the problem that sets up for a
16 post-TIA patient, don't you?
17 MR. LADNER: Object to form.
18 THE WITNESS: It can be -- it can be a
19 problem like that, yes, but -- but to make
20 it easier for you and everybody else to
21 understand, I think if you can go back to
22 your Exhibit 1, Chaudhry Exhibit 1, was it?
23 Q. (By Mr. Holloway) Sure. Let me pull it up.
24 Just a second.
25 A. Yeah. I'll give you two examples.
66
1 Q. So this may or may not be the one you have
2 in mind, but this is Exhibit 1. What would you like
3 to talk about?
4 A. One second. Can you go to the next page.
5 Q. The next page was number -- was Exhibit 2.
6 A. Next page.
7 Q. That's Exhibit 3.
8 A. Next page.
9 Q. Exhibit 4. This one is a two-page document.
10 A. One, two, three, four, five, six -- can you
11 read No. 7 for me?
12 Q. This here (indicating)?
13 A. Yes.
14 Q. Yeah. So this statement says, "If an
15 emergency room patient comes in with a TIA, after the
16 TIA ends, the hospital can either (a), discharge the
17 patient with instructions to return in the event of
18 later stroke symptoms, or (b), admit the patient to
19 the hospital for observation."
20 A. And in a lot of cases, A is also correct and
21 would be standard of care --
22 Q. Sure.
23 A. -- right?
24 And what would be the scenario about number
25 of hours here and there in that situation. What the
67
1 standard of care -- that is part of the standard of
2 care. And plus, to add a third point to that is that
3 now we also have a clinical decision unit in the
4 hospital, a CDU, where patients get observed in the
5 hospital and they don't get formally admitted as
6 inpatient for observation. So a lot of our TIA
7 patients and everywhere, any hospital that I know of
8 who has a CDU, they get observed there as well. So do
9 you see my point?
10 Secondly, the other example that I want --
11 do you have anything to say about that or do you want
12 to ask anything about that or no?
13 Q. For now, I'm happy to let you give -- give
14 any statement you want to give, but I'm --
15 A. Okay.
16 Q. I'm not inclined to answer your questions.
17 A. Okay.
18 Q. If you have more -- if you have more that
19 you'd like to say about this, I'm happy to let you say
20 it.
21 A. Yeah, so the point A is basically the one
22 that I think we all should be comparing this scenario
23 to. And also the -- the part where they don't get
24 formally admitted in the hospital, they get admitted
25 in CDU under observation.
68
1 And the second point that I also want to
2 mention is that -- I'll take another example of a
3 patient let's say who gets admitted with chest pain.
4 And they're admitted on the telemetry floor and we
5 admit them for observation and for possible further
6 testing for ischemic cardiac disease.
7 They also get their vitals checked every
8 four -- every four hours. But if they develop chest
9 pain and they have an ST elevation MI, the time to --
10 the time to let say what we call door-to-balloon time
11 is 90 minutes.
12 So -- so ideally, in an ideal situation,
13 things can be different, but in a realistic
14 situation -- in a realistic scenario, we also
15 discharge patients from the emergency department after
16 a TIA when their symptoms are resolved. It's based
17 off of the clinician's judgment and everything and the
18 risks and benefits.
19 Q. Okay. Let me go back and ask some
20 questions. So let me make sure that I'm -- we've
21 actually -- I'm going to recap the things that I think
22 we've established just to make sure that we're on the
23 same page here.
24 So I think you've testified -- correct me if
25 I'm wrong. I think you've testified that the neuro
69
1 assessments nurses do at Emory do not tell you last
2 known well. You knew that at the time. It was common
3 knowledge at the time, and it's still the case today.
4 A. I believe so. True.
5 Q. Okay. So let's talk about what that means.
6 First of all, let me go back to -- let me go back to
7 this marketing by Emory. So you see here this is
8 emoryhealthcare.org, the stroke center. Emory says,
9 "Every second counts when it comes to caring for
10 someone who has had a stroke."
11 Do you see that?
12 A. Yes.
13 Q. It's true, isn't it?
14 A. True, yes.
15 Q. Emory says, "Specialized care for stroke
16 patients. Our teams make sure you get the right care
17 in every stage of treatment from the first stroke
18 symptom through recovery."
19 Do you see that?
20 A. Yes.
21 Q. Do you still believe what you said earlier
22 that accurately identifying the last known well is
23 crucial to the safety of a stroke patient?
24 A. Yes.
25 Q. So getting the right care at every stage of
70
1 treatment, doesn't that mean that if you are -- if
2 you've admitted a post-TIA patient for observation,
3 somebody better be doing neurological assessments that
4 let you find the accurate, true last known normal;
5 right?
6 A. In an ideal situation, yes. I agree with
7 you. Like I said initially, I should be in the room
8 24/7 and examine them frequently. That would be the
9 ideal situation. That should be done for each and
10 every patient. Each and every patient does not matter
11 what -- what illness they come in with. There should
12 be 24/7 physician monitoring over them.
13 Q. We don't live in -- in an ideal world, do
14 we?
15 A. Thank you. No.
16 Q. In an ideal world, nobody would have a
17 stroke; right?
18 A. Yeah. You can define ideal, but that
19 doesn't --
20 Q. Well, would your ideal include a world in
21 which people are having strokes?
22 A. Ideal world, no.
23 Q. Okay. Why don't we focus this discussion on
24 the real world that we all live in. Can we do that
25 going forward?
71
1 A. Sure. Yeah.
2 Q. In the real world that we live in, do you
3 think -- do you think this marketing website by Emory
4 Healthcare is describing what happens in an
5 unobtainable ideal world?
6 A. It's describing what? Say that again.
7 Q. This marketing website by Emory, do you
8 think where it says, "Our teams make sure you get the
9 right care at every stage of treatment," do you take
10 that to be a fantasy description of what might happen
11 in a -- in an ideal world or do you take that to be --
12 A. All --
13 Q. Let me finish the question.
14 A. Okay.
15 Q. Do you take that to be a statement of fact
16 by Emory about what they do in the real world?
17 A. Yeah, what we do in the real world.
18 Q. Okay. So talking about the real world, in
19 the real world, is it crucial that a post-TIA patient
20 admitted for observation at an Emory primary stroke
21 center has somebody doing neuro assessments that let
22 you identify the correct last known normal if they
23 have a stroke later?
24 A. Yeah, that would be an excellent thing to
25 have.
72
1 Q. And in the real world, what happens instead,
2 according to your testimony, is the job of the routine
3 neuro assessments goes to nurses who are not qualified
4 or at least, in fact, do not do assessments that let
5 you identify the last known normal.
6 MR. LADNER: Object to form. You can
7 answer it.
8 THE WITNESS: True.
9 Q. (By Mr. Holloway) And that's not some
10 one-time aberration that just happened to Stefan Lane
11 because he was unlucky. That, on your testimony, is
12 how Emory does it routinely; right?
13 MR. LADNER: Same objection.
14 THE WITNESS: For a TIA patient, yes,
15 who could have also been discharged home.
16 Q. (By Mr. Holloway) Okay. So let's talk
17 about what that means for a patient like Stefan or for
18 any post-TIA patient. By the way, before we do that,
19 when Stefan was admitted for observation, did you have
20 a conversation with him and Janet in which you
21 explained it is vitally important that if you have a
22 stroke in ten hours or 15 hours that we know the last
23 known well; however, we are not going to have
24 qualified people do neurological assessments that
25 would let us find out the last known well?
73
1 Did you have a conversation like that with
2 Stefan or Janet?
3 MR. LADNER: Object to form.
4 THE WITNESS: I don't remember saying
5 that specifically to them.
6 Q. (By Mr. Holloway) Do you believe you had
7 that conversation?
8 MR. LADNER: Same objection.
9 THE WITNESS: I don't remember.
10 Q. (By Mr. Holloway) I understand you don't
11 remember. In the ordinary course of things, is that a
12 conversation you would have with a post-TIA patient
13 you're admitting for observation?
14 MR. LADNER: Same objection. You can
15 answer the question.
16 THE WITNESS: Yeah, I would tell them
17 about the -- the protocol and the
18 admission -- we would admit them in the
19 hospital. We would observe them. We would
20 also -- basically there are two more things
21 that each patient gets -- gets done when
22 they get admitted in the hospital and they
23 are admitted under observation is that if
24 they have a -- if they had a TIA or a
25 stroke, we try to determine why they had
74
1 it. And so we do -- we do several things.
2 And then the second thing, which the reason
3 why they get admitted for observation is
4 also we -- what we can do to initiate the
5 treatment or increase the treatment if
6 they're already on some to prevent the next
7 one from happening. So to initiate that
8 treatment and then monitor them and make
9 sure they don't develop any side effects,
10 et cetera.
11 So I would explain all of that when
12 they get admitted and do further tests,
13 detailed tests. This takes time to do and
14 then to get the results.
15 MR. HOLLOWAY: Objection,
16 nonresponsive.
17 Q. (By Mr. Holloway) The question is: When
18 you admit a post-TIA patient for observation, do you,
19 as a routine matter, tell them it is vitally important
20 for your health and safety that we know the last known
21 well in the event you develop a stroke later, but we
22 are not going to assign the task of neurological
23 assessment to people qualified to do assessments that
24 would let us figure out the last known well? Is that
25 a conversation you routinely have --
75
1 A. I cannot say that.
2 MR. LADNER: Object to form. You can
3 answer. You can answer it.
4 THE WITNESS: Whatever you just said,
5 I do not say that.
6 Q. (By Mr. Holloway) Of course not because it
7 would be crazy to say that, wouldn't it?
8 MR. LADNER: Object to form.
9 THE WITNESS: I would not say that.
10 Q. (By Mr. Holloway) Right. You wouldn't say
11 it because it's -- it would be a ridiculous thing to
12 say, wouldn't it?
13 MR. LADNER: Object to form.
14 THE WITNESS: Yeah, I don't know -- I
15 don't have an answer to that.
16 Q. (By Mr. Holloway) Well, do you think it
17 would be a reasonable thing to say?
18 A. It would not be a reasonable thing to say.
19 Then why are we admitting that? Then we should just
20 send them home.
21 Q. Very good question.
22 A. Right. And you would keep them for all the
23 reasons that I described earlier.
24 Q. All right. But I -- let's go back to this
25 hypothetical case we were discussing a little while
76
1 ago. So back to Exhibit Chaudhry 7. So you said
2 earlier that in the scenario where the assessments
3 were reliable enough that you could figure out the
4 last known well, even in that scenario, this -- what's
5 playing out in this hypothetical with four-hour
6 monitoring ends up putting the patient in a very dicey
7 situation because with only four-hour monitoring, by
8 the time the assessment shows stroke symptoms, there's
9 only 30 minutes left here before the tPA window
10 closes.
11 Do you remember all that?
12 A. Yes.
13 Q. So in the real world, though, these
14 neurological assessments that are done every four
15 hours, these aren't done by -- at Emory, these routine
16 assessments that are ordered, they're not done by
17 physicians, are they?
18 A. The Q4 hour checks, no. They're done by the
19 nurses.
20 Q. Right. So what you're telling me -- tell me
21 if I've got this right. What you're telling us is
22 that in -- in the real world where these assessments
23 are actually done by nurses, what's going to happen is
24 by the time a physician get s called at 5:00 a.m.
25 here, the physician is going to consider tPA; right?
77
1 A. Yes. If there's some concerning, et cetera.
2 Q. And the physician is going to have to figure
3 out when the last known well was.
4 A. Yes.
5 Q. But what you're saying now is if -- if this
6 assessment was done by a nurse, then it's no good for
7 telling you the last known well; right?
8 A. Yeah, because their assessment will not
9 determine their last known well.
10 Q. Right. So the last known well is going to
11 go back past that four-hour mark, back past the time
12 when she came in with the symptoms to whatever --
13 whatever her original onset of symptoms was; right?
14 A. Or when they were evaluated by the ER
15 physician and then hospitalist after that and
16 neurologist after that and after the rounding
17 physician, the rounding neurologist, et cetera.
18 Q. We'll come back to those things you just
19 suggested as possibilities in a minute, but let's
20 stick with this scenario right now. In this scenario,
21 when the physician gets the call from the nurse at
22 5:00 a.m., the physician has to find the last known
23 well, and it is not this first neuro assessment, is
24 it?
25 A. Well, that was done by the ER provider.
78
1 Q. We're changing the hypothetical to fit the
2 real world. In the real world, these regularly
3 scheduled neuro assessments are done by nurses.
4 You've already told us that.
5 A. Yes, those assess -- it says neuro
6 assessment. So I don't know who did that. If the
7 nurses did that on the floor, then, yeah, that would
8 not establish the last known normal.
9 Q. Okay. So the physician -- again, at 5:00
10 when the physician gets called by a nurse, say, Hey,
11 hypothetical Nancy has symptoms again. In considering
12 tPA, the physician has to find the last known normal,
13 and it's not that nurse-performed neuro assessment.
14 It's sometime earlier; right?
15 A. True.
16 Q. And that means this -- even this paltry
17 30 minutes that would be -- that the tPA window would
18 be open for if it was a -- if the first neuro
19 assessment had been done by a physician, even that
20 30 minutes is gone now; right?
21 A. It depends.
22 Q. Well, in a scenario where there is no neuro
23 assessment by a physician before -- you know, let's
24 say -- here. To account for one of the possibilities
25 you suggested, let's say at 15 minutes -- 15 minutes
79
1 after midnight let's say the ER physician does an
2 assessment and it established, say, neuro normal.
3 Sorry. My pen does not write great on this.
4 So you were suggesting earlier that when the
5 patient comes into the ER, an ER doc is going to do an
6 evaluation; right?
7 A. Yes.
8 Q. Okay. So we'll add that into the scenario
9 here. So at 15 minutes after midnight, we have that
10 and the patient was neurologically normal. So that --
11 as your -- according to your testimony, that would
12 establish a last known normal; right?
13 A. Yes.
14 Q. Okay. So then for clarity, let's walk
15 through the scenario then. So then a nurse -- so then
16 after that, there's an order for neuro monitoring
17 every four hours; okay?
18 A. Yes.
19 Q. And then a nurse performs a scheduled neuro
20 assessment at 1:00 a.m. pursuant to that order; okay?
21 A. Yes.
22 Q. Then about an hour 45 minutes later,
23 hypothetical Nancy starts to have stroke symptoms
24 again. You with me?
25 A. Okay.
80
1 Q. And then at 5:00, a nurse does another neuro
2 assessment; okay?
3 A. Yes.
4 Q. Nurse calls the doctor. The doctor is going
5 to consider tPA; right?
6 A. Yes.
7 Q. So the doctor has to find the last known
8 well; right?
9 A. Yes.
10 Q. And according to your testimony, this neuro
11 assessment by the nurse does not establish the last
12 known well.
13 A. Huh-uh (negative). No.
14 Q. So you have to look all the way back to the
15 examination done by the ER physician; right?
16 A. Yes.
17 Q. And that is more than four and a half hours
18 ago, isn't it?
19 A. Yeah.
20 Q. So this patient is out of luck.
21 MR. LADNER: Object to form.
22 THE WITNESS: Yeah. In this scenario,
23 yeah.
24 Q. (By Mr. Holloway) This patient cannot get
25 tPA; right?
81
1 A. Yeah, just like -- just like a TIA patient
2 who would get discharged home, similar to that.
3 MR. HOLLOWAY: Objection,
4 nonresponsive.
5 Q. (By Mr. Holloway) This patient -- let's
6 focus on this patient who is in the hospital. Let's
7 not -- for the moment, let's not talk about other
8 patients. Let's talk about this patient.
9 A. Yes.
10 Q. This patient is out of luck. This patient
11 cannot get tPA; right?
12 MR. LADNER: Object to form.
13 THE WITNESS: Yeah, they will be --
14 according to your example, they will be out
15 of the window.
16 Q. (By Mr. Holloway) So if that patient is
17 suffering a blockage that's going to start killing
18 brain tissue --
19 A. Yeah.
20 Q. -- tPA is not available to that patient to
21 save the brain tissue, is it?
22 A. Yeah, and to prevent this from happening,
23 then I guess the patient will have to be admitted to
24 the ICU.
25 Q. Let's just stick with the questions, please.
82
1 So the reason this patient is out of luck is
2 just because the hospital assigned the task of the
3 regular neuro assessments to somebody who is not
4 competent to do an assessment that would let you
5 figure out the last known well; right?
6 MR. LADNER: Object to form.
7 THE WITNESS: Not -- not competent,
8 but they're not told to do that. There's a
9 difference.
10 Q. (By Mr. Holloway) And that's the way it was
11 at Emory in December 2017. That's the way it is today
12 in August 2020.
13 MR. LADNER: Objection, asked and
14 answered multiple times. You can answer it
15 again.
16 THE WITNESS: Yeah.
17 Q. (By Mr. Holloway) Are you okay with that?
18 MR. LADNER: Object to form.
19 THE WITNESS: I'm sure there are
20 definitely improvements that can happen,
21 but like we discussed about ideal
22 situations and then -- and the tasks that
23 we can do. Like, if this patient was
24 admitted in the ICU and we did Q1 hour
25 neuro checks, that would give enough time
83
1 for the nurses to call the provider,
2 whoever is there, to do everything and
3 things could have been done on time. But
4 unfortunately, that is not the standard of
5 care.
6 Just like a TIA patient who gets
7 admitted -- or actually who comes to the ER
8 and their symptoms get resolved, they also
9 get discharged home to come back if their
10 symptoms recur or they get admitted in CDU,
11 you know. If this patient, if this
12 scenario would have happened in the ICU, we
13 would have caught that TIA or stroke
14 happening right after 1:30, and that was
15 two hours, two hours after the onset or
16 from the last known normal and that patient
17 would have gotten -- if they don't have any
18 contraindication, they would have gotten
19 tPA.
20 So you have to keep that in mind.
21 MR. HOLLOWAY: Objection,
22 nonresponsive.
23 Q. (By Mr. Holloway) The question was: Are
24 you okay with a system in which patients who might be
25 able to receive tPA safely and who need it are
84
1 deprived of it because the neuro assessments are given
2 to people who can't do an assessment that lets you
3 figure out the last known well? Are you okay with
4 that, Dr. Chaudhry?
5 MR. LADNER: Object to form. Object
6 to form, asked and answered.
7 THE WITNESS: I mean, what can you do?
8 Can you have anything better than standard
9 of care?
10 Q. (By Mr. Holloway) I think you're saying
11 this is -- this is a lousy situation, but it's what
12 we're stuck with at Emory. Is that --
13 MR. LADNER: Object -- object to form.
14 THE WITNESS: No, that's not what I'm
15 saying.
16 Q. (By Mr. Holloway) Are you saying this is a
17 good situation?
18 A. No, I'm definitely not saying that.
19 Q. This is a bad situation, isn't it?
20 A. I think we -- they have -- they probably
21 have to make improvements in what determines what a
22 stroke center is, et cetera --
23 Q. Right.
24 A. -- in all the hospitals. And I think
25 there's one major standard which is applied and which
85
1 happens in every facility which calls themselves a
2 stroke center. So it's not -- I don't believe -- I
3 don't know the details, but I don't believe it's a
4 strictly Emory problem.
5 Q. You're -- you've only ever worked at Emory;
6 right?
7 A. After my residency.
8 Q. That's what I mean, after residency.
9 A. Right. Yeah. I did three years of training
10 there.
11 Q. Has anybody told you that at other primary
12 stroke centers around the country, routine
13 neurological assessments are given to nurses who are
14 not capable of doing assessments that identify the
15 last known well?
16 MR. LADNER: Object to form.
17 THE WITNESS: No, no one has told me
18 like that.
19 Q. (By Mr. Holloway) But looking back at
20 this -- at this patient, you know, this hypothetical
21 patient Nancy who had the kind of routine assessments
22 done at Emory by nurses, this lady -- well, for an
23 ischemic stroke, we agreed earlier, didn't we, that
24 there are two primary treatments. It's either tPA or
25 mechanical thrombectomy; right?
86
1 A. Yes.
2 Q. And a mechanical thrombectomy, that's for
3 large-vessel occlusions; right?
4 A. Yes.
5 Q. If -- if this hypothetical patient Nancy, if
6 she had a small-vessel occlusion like Stefan Lane had,
7 mechanical thrombectomy is not going to be an option
8 for her; right?
9 A. Yeah. I believe so. I'm not an expert, so
10 I don't know what the interventional neuroradiologists
11 can do. I don't know because there's -- yeah, I'm not
12 an expert, but they can -- they can -- I mean, they
13 can suck the clot out and -- and also inject
14 medication specifically in that area. So I don't know
15 the details.
16 Q. Well, you do know this well enough to know
17 that there are some ischemic stroke patients for whom
18 thrombectomy is not an option.
19 A. All providers know that.
20 Q. Sure.
21 A. But all providers cannot determine that.
22 Q. Sure.
23 A. Yeah.
24 Q. So let's say that hypothetical Nancy here is
25 one of the people who has a clot that can't be grabbed
87
1 by mechanical thrombectomy. You with me?
2 A. Okay. Yeah.
3 Q. So if she's one of those patients, she
4 doesn't have -- of the two primary treatments,
5 thrombectomy is ruled out and now tPA is also ruled
6 out because this assessment was done by somebody not
7 competent to identify last known well.
8 MR. LADNER: Object to form.
9 THE WITNESS: Again, you mention
10 competent. Why are you saying competent?
11 Q. (By Mr. Holloway) I'll rephrase it.
12 A. Okay.
13 Q. So our hypothetical Nancy, if thrombectomy
14 is not appropriate for the clot she has, that only
15 leaves her with tPA; right?
16 A. Yes.
17 Q. And in this hypothetical, she is denied tPA
18 because the neuro assessment that was done by the
19 nurse was not adequate to identify Nancy's last known
20 well; right?
21 A. Yes.
22 Q. So of the two primary treatments for stroke,
23 thrombectomy is out in this hypothetical because of
24 the nature of the clot, and tPA is also out, leaving
25 her with zero; right?
88
1 A. Right.
2 Q. This patient is just doomed to suffer
3 whatever the clot is going to do to her brain,
4 whatever tissue it's going to kill, whatever
5 disability it's going to leave her with, if it's going
6 to kill her, she's just doomed to suffer it.
7 MR. LADNER: Object to form.
8 Q. (By Mr. Holloway) Because the neuro
9 assessment was not adequate to identify last known
10 well.
11 MR. LADNER: Object to form.
12 Q. (By Mr. Holloway) True?
13 A. True. In this situation, true.
14 Q. And part of Emory's position in this lawsuit
15 and part of Dr. Obideen's position in this lawsuit and
16 now part of your position in this lawsuit is that's
17 what happened with Stefan Lane; right?
18 MR. LADNER: Object to form.
19 THE WITNESS: Yeah. We can say yes.
20 Yeah.
21 Q. (By Mr. Holloway) And Emory is going out
22 advertising itself as a stroke center; right?
23 A. Yes, Johns Creek.
24 Q. I'm sorry. I don't mean to interrupt.
25 And Emory is telling the ambulance services,
89
1 We are stroke -- we're a stroke center. Bring your
2 stroke patients to us; right?
3 MR. LADNER: Object to form.
4 THE WITNESS: Right.
5 Q. (By Mr. Holloway) And they're doing that
6 knowing that post-TIA patients like Stefan are going
7 to -- in at least a lot of cases they're going to be
8 doomed to have tPA refused because the neurological
9 assessments are not adequate to identify last known
10 well.
11 MR. LADNER: Object to form.
12 THE WITNESS: Yeah.
13 Q. (By Mr. Holloway) Okay. I'll move on from
14 this. Let me go through some more statements just to
15 make sure that we agree on what I think are some
16 points we can agree on. Give me a second here.
17 I'm putting on the screen a document I've
18 marked Exhibit Chaudhry 8. I used this almost
19 identical document the other day with Nurse Bryan
20 Mays. Have you seen this document before?
21 (Plaintiffs' Exhibit 8 was marked for
22 identification.)
23 THE WITNESS: I had one, yeah, with
24 similar questions. I don't know if it was
25 exactly --
90
1 MR. LADNER: Dan, we haven't -- we
2 haven't provided him that. I think he's
3 talking about the request for admissions.
4 MR. HOLLOWAY: Okay.
5 Q. (By Mr. Holloway) All right. Let's just go
6 through these one by one like we did with the others.
7 Just a second.
8 MR. LADNER: Was that an exhibit? I
9 don't think you marked any exhibits to
10 Bryan Mays' deposition.
11 MR. HOLLOWAY: I sent it -- I e-mailed
12 it around to you and the court reporter
13 with an exhibit sticker on it, but during
14 the deposition, I did not identify it as an
15 exhibit.
16 MR. LADNER: Okay.
17 MR. HOLLOWAY: Here, I've -- for
18 better or worse, I'll mark this clean copy
19 for this exhibit.
20 Q. (By Mr. Holloway) One. "Emory Healthcare
21 advertises Emory Johns Creek Hospital as a primary
22 stroke center." Agreed?
23 A. Yes.
24 Q. Two. "Stefan Lane came to the Emory Johns
25 Creek ER reporting symptoms of a mini-stroke."
91
1 A. Yes.
2 Q. Three. "The mini-stroke ended, but while
3 still at Emory Johns Creek, Mr. Lane had at least one
4 more mini-stroke for at least two mini-strokes in nine
5 hours."
6 A. True.
7 Q. Four. "A mini-stroke often foreshadows a
8 full-blown stroke."
9 A. It can be true, but I don't know if "often"
10 is the right word.
11 Q. Why don't I --
12 A. You can say "can."
13 Q. Yeah. I'll edit it.
14 MR. LADNER: Dan, same continuing
15 objection to this document.
16 MR. HOLLOWAY: Yes. Sorry. Give me a
17 second here.
18 Q. (By Mr. Holloway) Okay. With that edit,
19 you agree?
20 A. Yes.
21 Q. Five. "A neurology consult was not ordered
22 for Mr. Lane until 15 and a half hours after he
23 arrived in the ER."
24 A. I believe so.
25 Q. Six. "A neurology consult was not performed
92
1 for Mr. Lane until approximately 24 hours after he
2 arrived in the ER."
3 A. I believe so.
4 Q. Seven. "While Mr. Lane was being examined
5 by a neurologist, Mr. Lane was actively suffering a
6 stroke."
7 A. I believe so.
8 Q. Eight. "The neurologist did not diagnose
9 Mr. Lane with a stroke."
10 A. At that moment?
11 Q. Yes.
12 A. I don't remember. I don't know.
13 Q. Nine. "While Mr. Lane was being examined by
14 a neurologist, Mr. Lane was within the time window for
15 clot-buster medication to treat the stroke."
16 A. I don't know.
17 Q. Ten. "The neurologist did not order
18 clot-buster medication or otherwise treat Mr. Lane for
19 a stroke."
20 A. I don't know.
21 Q. Eleven. "The neurologist highly suspected
22 Mr. Lane's symptoms were from a psychiatric problem."
23 A. I don't know.
24 Q. "Mr. Lane's symptoms were not because he had
25 a psychiatric problem."
93
1 A. I don't know.
2 Q. All right. We'll go through the ones in
3 some more detail where you didn't know. So that
4 starts with eight. Let me -- let me just show you
5 the -- the record. I'm just going to put up on the
6 screen, Dr. Obideen's consult note, and it'll speed
7 things up if I just let you read through the whole
8 thing.
9 You can -- if you have a hard copy there,
10 that's fine, if it's easier to read, or I can put it
11 up on the screen and just tell me when to go to the
12 next page. It's only a few pages.
13 MR. HOLLOWAY: And for the record,
14 this is a consultation note from Dr.
15 Obideen dated 12/15/2017, 23:22 Eastern
16 Standard Time, and on this copy, at least,
17 the Bates number is EJCH102 and this goes
18 on to Bates EJCH107.
19 Q. (By Mr. Holloway) I'll give you a second to
20 read through this and just tell me when to go to the
21 next page.
22 A. Okay.
23 Okay. Next page. Next page. Next page.
24 Next page. Next page. Can you --
25 Q. Yeah.
94
1 A. Okay.
2 Q. Okay. Now let me go back to the document I
3 had up. Just a sec. So the statement I was asking
4 you -- that's not what I meant. The statement I was
5 asking about was this one: "The neurologist did not
6 diagnose Mr. Lane with a stroke." You agree?
7 A. I don't know. It's difficult to say because
8 he has not mentioned a specific diagnosis.
9 Q. Well, without mentioning a diagnosis, a
10 specific diagnosis -- scratch that. I'll re-ask it.
11 He obviously did not mention -- he didn't
12 say, I diagnosed Mr. Lane with a stroke. Can we start
13 there?
14 A. Yeah, he didn't mention that in his note.
15 Q. He says -- he talks about having high
16 suspicion of conversion disorder or -- I don't
17 remember the exact language, but you recall that;
18 right?
19 A. Yeah, he did mention that.
20 Q. So do you think maybe Dr. Obideen did
21 diagnose Stefan with a stroke or you're unsure or --
22 A. I think so because that's why he's doing
23 further workup.
24 Q. Okay. You think -- you think he did.
25 A. Yeah, there's -- so -- so usually we have a
95
1 differential diagnosis in our mind, and based off of
2 that, then you order further tests. So I believe that
3 stroke was definitely in his differential. That's why
4 he is ordering that CTA of head and neck.
5 Q. So it's low down on his differential; right?
6 MR. LADNER: Object to form.
7 THE WITNESS: We don't know. He
8 hasn't numbered them. And he should be
9 able to answer you. I don't know what he
10 was thinking when he's writing that note,
11 et cetera.
12 Q. (By Mr. Holloway) Okay. But you can read
13 the note; yes?
14 A. Yeah.
15 Q. You see this language, "I have high
16 suspicion that he has conversion/somatoform disorder."
17 Do you see that?
18 A. Yeah.
19 Q. He does -- as you said, he does say, "I'm
20 going to order CTA head and neck to rule out any
21 basilar artery stenosis"; right?
22 A. Right.
23 Q. And he says, "If these studies are
24 unremarkable and the MRI is negative for acute stroke,
25 then mostly the patient has conversion disorder."
96
1 A. Okay.
2 Q. In your mind, is that a stroke diagnosis?
3 MR. LADNER: Object to form.
4 THE WITNESS: I have to -- I have to
5 do -- I have to determine that myself.
6 Q. (By Mr. Holloway) Determine what?
7 A. If the patient is having a stroke or not.
8 Q. I'm not asking about what your diagnosis
9 would be. I'm asking --
10 A. You just did.
11 Q. No. No. We're misunderstanding each other
12 then.
13 A. Okay.
14 Q. My question is: From reading Dr. Obideen's
15 consult note --
16 A. Uh-huh (affirmative).
17 Q. -- does this read to you like he is
18 diagnosing stroke?
19 MR. LADNER: Object to form.
20 THE WITNESS: Possibly, yes. If not,
21 then why would he order all those tests?
22 Q. (By Mr. Holloway) There's a difference --
23 A. He ordered an MRI with thin cuts despite
24 having a normal MRI before. If he's not thinking
25 about a stroke and if he thinks it's a conversion or
97
1 somatoform disorder which is causing all these
2 symptoms, why would he do that? He would not order an
3 MRI of the brain through brainstem with
4 three-millimeter cuts for a conversion disorder.
5 Q. Tell me this, if you thought the patient was
6 undergoing a stroke, would you order an MRI routine so
7 that it would get done two days later?
8 MR. LADNER: Object to form.
9 THE WITNESS: So routine MRIs usually
10 doesn't take that long. They usually come
11 back within that day. I would say
12 12 hours.
13 Q. (By Mr. Holloway) Let me -- let me ask a
14 different question then. If you thought a patient
15 might be having a stroke while you were examining
16 them, would you order an MRI routine with the
17 expectation that it might come back in 12 hours?
18 A. If it's not going to change my management,
19 then yes.
20 Q. That is if -- if -- what you're saying is
21 if -- if tPA has already been ruled out because
22 there's no last known well, there's no reliable
23 neurological assessment in the last four and a half
24 hours that would establish the last known well, then
25 tPA doesn't matter and basically you can wait as long
98
1 as you want because unless it's a thrombectomy
2 patient, there's nothing to do but wait and see how
3 bad it gets; right?
4 A. True. Yeah.
5 Q. Okay. In any event, this -- I just want to
6 make sure I understand your testimony. As you read
7 Dr. Obideen's consult note, does that sound to you
8 like he is diagnosing Mr. Lane with a stroke?
9 MR. LADNER: Object to form, asked and
10 answered.
11 THE WITNESS: I did answer you that.
12 Q. (By Mr. Holloway) I know, but I'm not sure
13 if you said -- it was something -- it was either a yes
14 or a maybe. I'm trying to figure out which it was.
15 A. He's doing workup for it, so he's
16 considering it. He hasn't made a final diagnosis of
17 anything yet. That's why the patient gets admitted in
18 the hospital so they get worked up to make a
19 definitive diagnosis.
20 Q. Okay. You would agree with me, then, I take
21 it, if the statement were "did not definitively
22 diagnose Mr. Lane with a stroke," that much you agree
23 with; right?
24 A. No, I would not say that either.
25 Q. No, you wouldn't even agree with that?
99
1 A. Huh-uh (negative).
2 Q. So how do you -- what do you read this --
3 scratch that.
4 In your mind, is there a difference between
5 making a diagnosis and doing testing to identify a
6 problem?
7 A. Yeah. So that's why we do possible. So if
8 we have suspicion of something when we write our
9 assessment and plan, we say possible this, possible
10 that. We could be wrong, but we do workup based off
11 of that. You take the symptoms. You come up with a
12 differential diagnosis, and then you -- and then you
13 workup based off of that.
14 So some people just write it up like that
15 like he did in a paragraph. I usually break it down
16 into problems. So it's a different way of doing
17 things. So that's why I do not want to say that he
18 is -- he's definitely considering a stroke there. I
19 would take away that "did not" part of it. He's
20 definitely considering the stroke.
21 Q. Okay. All right. Let me -- so you think to
22 be true the statement should read -- just a sec. The
23 neurologist did definitively diagnose Mr. Lane with a
24 stroke. You think that's a true statement?
25 A. So I cannot say that because I don't know
100
1 what he's thinking in his mind. If he would have
2 documented that, I would have said yes. So I cannot
3 go inside his brain at that time and see what he's
4 thinking, so it's very difficult for me to say that.
5 But thinking -- but looking at his note and
6 how it's all worded, he's definitely thinking that
7 he's having a stroke. Therefore, he's ordering the
8 CTA head and neck and a second MRI.
9 Q. Okay. When you call a code stroke, do you
10 order an MRI stat or routine?
11 A. It depends. Usually you do not order an MRI
12 when there's a code stroke. We order a CT head
13 without contrast.
14 Q. I just want to close out this issue with
15 this statement eight. So I'm struggling to understand
16 your testimony on this.
17 A. I think it's more --
18 Q. I think you're -- I'm sorry. Go ahead.
19 A. Go ahead. You can finish.
20 Q. I think if I'm interpreting correctly,
21 basically you're -- you're saying you don't know if he
22 did or did not diagnose Mr. Lane with a stroke. Is
23 that it?
24 A. Okay. So to answer your question, the
25 neurologist did not diagnose Mr. Lane with a stroke is
101
1 a false statement. Not true.
2 Q. Okay.
3 A. Yeah. You can take the edit off and --
4 Q. Let me go back to where it is on the -- on
5 the first page and I'll change this from a question
6 mark to a red X.
7 A. Sorry, what did I say? Neurologist did not
8 diagnose Mr. Lane with a stroke?
9 Q. Right. And at first you said you didn't
10 know, and now you're saying that is a -- definitively
11 that is false statement, that No. 8; right?
12 A. Yeah, that's a false statement. I think he
13 was considering a stroke. So that statement is not
14 true.
15 Q. Okay. Let's move on to nine. This was
16 another question mark. Some of this stuff, I think
17 we'll agree on. This, you agree with. "One type of
18 stroke is an ischemic stroke caused by a clot that
19 blocks blood flow to the brain."
20 A. Yes.
21 Q. We've already agreed on that. I'll let you
22 read it. We've already agreed on this as well; right?
23 A. Yes.
24 Q. Just for the -- for the written record, it
25 reads, "For a stroke caused by a clot, the first
102
1 option treatment is a clot-buster medication called
2 Alteplase IV r-tPA, also known as tissue plasminogen
3 activator, or tPA."
4 The only -- the only -- I'll just skip to
5 the points here that you might -- you'll agree, I'm
6 sure, with the statement, "The neurology consult was
7 performed at 2302 hours." Do you want me to show you
8 the time again?
9 A. I don't know about that.
10 Q. Yeah, let me -- let me show that to you
11 again. So here's the consult.
12 A. Okay.
13 Q. The service date/time says 2302, and then
14 perform information is 20 minutes after that.
15 A. Okay.
16 Q. So, I mean, that's -- that -- this part is
17 easy to agree with, right, the consult was performed
18 at 2302 hours?
19 A. I don't know where that service date/time
20 comes from, what determines that, who puts the
21 heading.
22 Q. When you create progress notes --
23 A. Yeah.
24 Q. -- is there a space for you to put in
25 service date and time?
103
1 A. No. I guess whenever we start it, it would
2 generate it. And then when you sign it, I think
3 that's the sign information is when he is done with
4 his note.
5 Q. I have seen -- I've seen sign information,
6 you know, that's days after the event. So they've got
7 three dates, three timestamps. There's a service
8 date/time, there's a perform information time and a
9 sign information.
10 A. There's not much difference between them.
11 Q. Yeah, here, those are the same.
12 A. Yeah.
13 Q. I take it that in the -- in the EMR system,
14 there must be a difference -- there's a -- you can
15 write your note and then it's a separate thing to sign
16 the note; is that right?
17 A. Yeah. So you can -- so this is done
18 electronically in the system. So when they would
19 start the note, that's where the 2302 would come at,
20 and then when that he would finish the note and sign
21 it, that's where that would come in.
22 What you're referring to is when a lot of
23 consultants and hospitalists, when we write our note,
24 especially the H&P and discharge summary, we dictate
25 them. So when we dictate them, it gets transcribed
104
1 and then it comes to us and then we sign them. So
2 then that can take a longer period of time.
3 Q. Sure.
4 A. So this is elec- -- this, I believe, is
5 electronically done. So it was started and then
6 signed in 20 minutes when he was finishing his note.
7 Q. So back to this statement, "The neurologist
8 consult was performed at 2302 hours," do you agree,
9 disagree?
10 A. So the note was done at that time because --
11 so I consider the con- -- the consult being performed
12 when the -- when the physician is actually evaluating
13 the patient and talks to them. This is after they
14 have done all of that and they have sat down at the
15 computer, logged in and started documenting all of it.
16 So it would be sometime prior to that.
17 Q. Okay. You think it was approximately at
18 2302 hours?
19 A. I don't know.
20 Q. Okay. So you just don't --
21 A. Yeah, I don't know, because it could be
22 hours before that. I don't know.
23 Q. Okay.
24 A. It could be right before it, so...
25 Q. The second statement, "Mr. Lane had been
105
1 given a neurological assessment about three hours
2 earlier at 2008 hours with no neurological deficit
3 noted."
4 Do you -- do you -- are you familiar with
5 that from your review of the records?
6 A. I'm actually not. I didn't review the rest
7 of it. I just reviewed my part when I was involved in
8 the case.
9 Q. Right. So let me show that to you. So
10 here, we have a neurological assessment performed by
11 Nurse Bryan Mays; right?
12 A. Yes.
13 Q. And you know Nurse Bryan Mays?
14 A. Yes. Yeah, he works there.
15 Q. So this is recorded at December 15th, 2017
16 at 2008 hours; right?
17 A. Right.
18 Q. And I'll let you read the highlighted text
19 here from that neurological assessment, but after
20 you've done that, I think you'll agree with me that it
21 did not note any neurological deficits.
22 A. Okay.
23 Q. Okay. So first of all, from our prior
24 discussion, I understand, you know -- I can anticipate
25 what your -- what other points you might want to make
106
1 about this. But to start with, just the plain
2 statement of fact, do you agree that Mr. Lane had been
3 given a neurological assessment three hours early --
4 about three hours earlier at 2008 hours with no
5 neurological deficit noted? Just that much, do you
6 agree with?
7 A. Whose neurological assessment?
8 Q. I just showed you Bryan Mays' neurological
9 assessment.
10 A. So that should be added to that.
11 Q. Well, do you -- okay. Well, let's start
12 there. Do you believe -- do you believe that Nurse
13 Mays conducted a neurological assessment?
14 A. Yeah. It mentions there.
15 Q. Okay. So is it true, then -- let's just
16 take the first phrase. "Mr. Lane had been given a
17 neurological assessment about three hours earlier,
18 2008 hours." Do you agree with that much?
19 A. Sure. Specifically Bryan Mays' neurological
20 assessment.
21 Q. And let's take the second part. Do you
22 agree that that neurological assessment showed no
23 neurological deficit?
24 A. Yes.
25 Q. Okay. So I think, then, that you agree with
107
1 the whole statement; true?
2 A. Yeah, if you're talking about neurological
3 assessments conducted by the nurse, yes.
4 Q. Okay. But I'm -- I'm not -- to set your
5 mind at ease, I'm not going to go through whole
6 argument at length here. I think if I understand your
7 position, your position is that notwithstanding all of
8 that, even taking into account Nurse Mays'
9 neurological assessment, Mr. Lane was still not within
10 the time window for tPA because the neuro assessment
11 Nurse Mays did was not adequate to identify the last
12 known well.
13 A. True.
14 Q. Okay. That's your position.
15 Okay. So let me go back and update this
16 No. 9. Also we can now convert this to an X for
17 disagreement; right?
18 A. Correct.
19 Q. Okay. Just from your review of the -- of
20 Dr. Obideen's consult note, can you now confirm that
21 this Statement 10 is true? "The neurologist did not
22 order clot-buster medication or otherwise treat
23 Mr. Lane for a stroke."
24 A. Yeah, the first part is true, but I don't
25 know what you mean by otherwise treatment Mr. Lane's
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1 stroke.
2 Q. Well, in what you've seen, have you seen any
3 treatment for a stroke that Dr. Obideen provided?
4 A. If you're talking about the two things that
5 we talked earlier about thrombectomy or tPA, those
6 two, he didn't order, no.
7 Q. Okay. I don't want to -- I don't want to
8 stretch you to agree with something that you're
9 hesitant to. Is it -- is it right that as to the
10 second part "or otherwise treat Mr. Lane for a
11 stroke," you still just don't know or do you know it
12 to be false?
13 A. Yes, 'cause that's a pretty broad term and
14 pretty broad sentence. Doing therapy is treatment for
15 a stroke. Doing -- giving aspirin, giving statin, I
16 mean, can be part of treating for a stroke. Taking --
17 monitoring patient on telemetry to monitor for
18 arrhythmias, that can be considered as treatment for a
19 stroke.
20 But if you specifically want to talk about
21 if the patient was given tPA or was considered for
22 thrombectomy, if it was ordered or not, those two
23 things, no, he didn't order that.
24 Q. If -- well, I'll just -- I understand your
25 testimony. For this document, I'll just leave it as
109
1 it is unless you think that mischaracterizes your
2 testimony.
3 A. I think it does. Because here so far
4 wherever we have reached he has not even gotten the
5 CTA result back; correct? So how can he -- I don't
6 know if it's indicated or not at that moment, but I
7 don't know if he considers thrombectomy at that time.
8 Q. How about if I specify the date. On
9 December 15th, he did not order tPA or otherwise treat
10 Mr. Lane for a stroke, can you agree with that?
11 A. Time as well. You can put that.
12 Q. Well, his -- his consult note is signed
13 about 30 minutes before midnight. Are you thinking
14 that maybe in those -- in the 38 minutes from when he
15 signed his note until December 16th that he might have
16 done some treatment?
17 A. Just for completeness sake.
18 Q. How about I say on 12/15, in --
19 A. At the time of his consult, if you can put
20 that.
21 Q. I'll do that. I'll do that. At the time of
22 his consult. Okay. With that edit, is this a true
23 statement?
24 A. Yes, I'm still not comfortable with "or
25 otherwise treat Mr. Lane for a stroke." That's a
110
1 pretty broad term for the reasons that I mentioned
2 before. And I would not add that to the statement.
3 I'm going to have a difficult time agreeing with that
4 completely.
5 Q. Okay. So I'll leave -- I'll leave the
6 question mark.
7 A. Sure. Yeah.
8 Q. But just to be clear, do you know of any
9 treatment Dr. Obideen ordered for Stefan Lane at any
10 time on December 15th or 16th?
11 A. I'll have to go back and review all the
12 records, which I haven't done, so I don't know.
13 Q. Right. You haven't reviewed the records.
14 Was that -- if you had been just left to your own
15 devices and had learned -- you know, learning that
16 you've been named as a defendant in a medical
17 malpractice case, would you have had an actual
18 curiosity about questions like whether Dr. Obideen
19 ordered treatment for a stroke?
20 MR. LADNER: Object to form.
21 THE WITNESS: If I was the only
22 person, yes.
23 Q. (By Mr. Holloway) Well, you're not.
24 A. Huh?
25 Q. You're not the only defendant. You know
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1 that; right?
2 MR. LADNER: Are you asking a
3 hypothetical or are you asking in this
4 case?
5 Q. (By Mr. Holloway) Have you been sued in
6 some other case that you haven't mentioned?
7 A. No. No. Never.
8 Q. Okay. In this case, if left to your own
9 devices, would you have had a natural curiosity about
10 facts like whether Dr. Obideen ordered any treatment
11 for a stroke?
12 MR. LADNER: Object to form.
13 THE WITNESS: I would definitely have
14 curiosity, yes.
15 Q. (By Mr. Holloway) Okay. But in any event,
16 the way things stand, you have not looked through the
17 records to find out if Dr. Obideen did or did not
18 order any treatment for a stroke for Mr. Lane or
19 December 15th or 16th?
20 MR. LADNER: Object to form, asked and
21 answered numerous times.
22 Q. (By Mr. Holloway) True?
23 MR. LADNER: You can answer it again.
24 THE WITNESS: Yeah, I haven't. I
25 haven't looked at everything in detail, no.
112
1 Q. (By Mr. Holloway) Okay. This Statement
2 No. 11, "The neurologist highly suspected Mr. Lane's
3 symptoms were from a psychiatric problem." Now at
4 least you know this to be true; right?
5 A. Yeah, he did mention that in his note.
6 Q. And the last one, "Mr. Lane's symptoms were
7 not because he had a psychiatric problem," do you know
8 that to be true?
9 A. I believe so.
10 Q. Okay. So is it -- is a checkmark a fair --
11 A. Sure.
12 Q. Okay. On this --
13 MR. LADNER: Dan, is this another good
14 time for a break? It's been about an hour
15 and a half.
16 MR. HOLLOWAY: This will go fast or at
17 least I think it'll go fast. Let me finish
18 up with this and then --
19 MR. LADNER: Okay.
20 MR. HOLLOWAY: -- then we can break.
21 Q. (By Mr. Holloway) So you've already read
22 the -- the note. I'll just go through these kind of
23 subpoints here quickly to see if you agree.
24 This is about suspecting the symptoms were
25 from a psychiatric problem. The first statement says,
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1 "The neurologist suspected this in part because Mr.
2 Lane said he couldn't move his left arm or leg at all,
3 but Mr. Lane had enough strength in his arm to keep
4 his hand from hitting his face in an arm-drop test."
5 Do you recall seeing that?
6 A. Yes.
7 Q. Okay. "Weakness without complete loss of
8 strength is a sign of stroke." Do you agree?
9 A. Yes.
10 Q. "Possessing some strength in an arm despite
11 weakness in the arm does not rule out stroke."
12 Agreed?
13 A. Yes.
14 Q. "The neurologist also suspected a
15 psychiatric disorder rather than stroke because of a
16 normal MRI from approximately 16 hours earlier." Do
17 you know that to be true?
18 A. I don't know. Maybe.
19 Q. Okay. So you don't know the timing of the
20 MRI?
21 A. No, I don't know what he was thinking, if he
22 considered that to be one of the reasons.
23 Q. Do you recall him mentioning the normal MRI?
24 A. Yes.
25 Q. Okay. Things can change in 16 hours.
114
1 A. Yes.
2 Q. "A normal MRI from 16 hours ago does not
3 rule out a stroke now."
4 A. True. True.
5 MR. HOLLOWAY: We're going to come
6 back. There is -- I forgot this one
7 additional thing I wanted to go through,
8 but I'm fine with doing a break right now.
9 THE WITNESS: Okay.
10 MR. LADNER: Okay. Dan, are we going
11 to have any issues finishing by 5:00?
12 MR. HOLLOWAY: No.
13 MR. LADNER: Great. Thanks.
14 MR. HOLLOWAY: Okay. We can take a
15 break. Off the record.
16 (A recess was taken.)
17 Q. (By Mr. Holloway) Dr. Chaudhry, I want to
18 have you -- have you walk us through -- I need to get
19 rid of this. Just a sec. Let me clear that.
20 I'd like you to walk us through what a
21 proper neurological assessment looks like that would
22 reliably identify a last known normal. Let me give us
23 a header here. So if you were doing such an
24 assessment, walk us through the steps that you would
25 perform.
115
1 A. So we can go by what Dr. Obideen did in his
2 note, in his physical exam. That is basically what we
3 try to follow.
4 Q. Okay.
5 A. If you -- if you can see that, his physical
6 exam, that is basically what we try to follow.
7 Q. Okay. Are you -- first, let me make sure
8 that -- are you able to see the whiteboard I've put
9 up?
10 A. Yes.
11 Q. Okay. So just walk us through what those
12 steps are.
13 A. Can I --
14 THE WITNESS: Do you have it in front
15 of you? Can I see it, Dr. Obideen's
16 consult note?
17 Q. (By Mr. Holloway) I'd prefer to get your
18 testimony based off of what you know rather than what
19 Dr. Obideen did. So do you --
20 MR. LADNER: I'm sorry to interrupt.
21 Go ahead.
22 Q. (By Mr. Holloway) Let me just start with
23 this question: Do you know how to perform a
24 neurological assessment that would reliably document a
25 last known normal?
116
1 A. Yes.
2 Q. Okay. So what's the first thing you would
3 do?
4 A. So I would go and evaluate the patient
5 visually.
6 Q. And what are you looking for in this visual
7 evaluation?
8 A. Any obvious deficits.
9 Q. Such as?
10 A. If they're responsive or not, are they
11 unresponsive, minimally responsive.
12 Q. Okay. What else? Can you give me some
13 other examples?
14 A. Of -- so responsiveness, alertness, how
15 oriented they are.
16 Q. Is that orientation, is that -- is that a
17 visual thing where you can just look at them and know?
18 A. You have to talk to them. So I would talk
19 to them and establish that, how alert also they are,
20 if they're understanding my question or not, if they
21 are oriented to time, place, location, to person, if
22 they know their name.
23 Q. Okay. So if we go back to visual
24 evaluation, what are -- what are the -- some of the
25 obvious deficits that you can see just by looking at
117
1 them?
2 A. Facial droop. That would be one. But prior
3 to that would be completely unresponsive, not awake at
4 all, not responsive.
5 Q. How do you -- I'm thinking just in terms of
6 for visual observation, can you help, just by looking
7 at them without talking, is this a way to distinguish
8 between someone who is unconscious and someone who is
9 just asleep?
10 A. Yeah, it's going to be difficult to tell,
11 but you can see if they are one -- and if you have
12 seen them before and if they are completely out.
13 Q. Okay. So responsiveness, facial droop.
14 Anything else for visual evaluation?
15 A. No, I think that's -- I'm sure I'll be
16 missing some, but definitely -- I think that
17 encompasses responsiveness, facial droop.
18 Q. Okay. So then on No. 2, the things where
19 you need to talk to them to figure it out, we've
20 talked about mental alertness, orientation. Any else?
21 A. And their speech.
22 Q. Difficulty speaking?
23 A. Yeah, if they have difficulty speaking. If
24 they're -- if they can actually speak at all. If
25 they're slurring their speech or if they are saying
118
1 the words right but they are not making any sense.
2 They are just speaking clearly, but not saying stuff
3 which is relevant at all.
4 Q. Okay. Anything else in this category before
5 we move on to the next category?
6 A. No, we can move on.
7 Q. Okay. What would be No. 3?
8 A. So then we would do a basic cranial nerve
9 exam, see if their pupils are equal or reactive to
10 light, if they both are either equal, if they're
11 reacting to light or not, and to accommodation. And
12 we do extraocular movements. If both eyes are moving
13 symmetrically, not -- and you can do facial sensory
14 exam. If they can feel both sides same or not.
15 Then you would ask them to give you a big
16 smile, see if both sides move equal or not. Then you
17 would ask them to clench their jaw tight and you see
18 if you -- you feel both muscles on each sides. If
19 they're equal or not, and if they can do that. Then
20 you ask them to stick their tongue out and you see if
21 they can -- if it's in midline, if they can do that.
22 Then you also look in the back of the throat. You
23 look at their uvula if it's -- if it's centered in the
24 position, if it's not deviated.
25 Also you ask them to close their eyes real
119
1 tight and you try to open it. And speech also
2 comes -- takes care of the cranial nerve. That takes
3 care of the swallowing part of the tongue. And, yeah,
4 that's pretty much it for the cranial nerve part of
5 the head.
6 Q. Okay. Anything else?
7 A. Yeah, we talked about sensation of both
8 sides of the face and the facial droop also comes in
9 the -- in this as well. Then you go -- then you can
10 do the -- you can move down in extremities and then
11 you see the strength and sensation in all four
12 extremities.
13 Q. How do you check that?
14 A. So you would check their extensor muscles,
15 if they're moving right. You would check their flexor
16 muscles, if they are moving right and against gravity
17 and against force that would establish the
18 five-out-of-five strength, if they can barely move it.
19 So zero would be no movement and five would be the
20 maximum force against -- against -- I mean movement
21 against force. And you also are judging -- they can
22 have five-out-of-five strength in both sides, they can
23 move against force, but one side can still be weaker
24 than the other. So you also determine that.
25 So you do that with upper extremities, both
120
1 upper arm and hands and fingers. And you also do that
2 with lower extremities, both muscles of the thighs and
3 the lower legs and feet. Then you can check for
4 ataxia, which ideally you ask them to walk, but if you
5 cannot, then you can do heel-to-shin touch. You ask
6 them to touch their heel of their foot on the knee and
7 touch it down, slide it down to their feet with their
8 eyes closed, if possible, that's much better.
9 And then you also do a pronator drift test,
10 which you ask them to close their eyes and put their
11 hands palm upwards and stay there for a period of I
12 think -- sometime 15 seconds, 20 seconds, and if they
13 are able to keep it there, then it's fine, but
14 sometimes if someone is having a deficit, then they
15 can have a drift. They can sway away.
16 Q. Okay. Anything else?
17 A. Then basic sensation in the lower extremity
18 on -- on the midpart of the body as well. Sensation.
19 If they can feel their abdomen, you touching them.
20 Usually you do it with sharp and dull. If they can
21 feel both, sharp touch or dull sensation. And then
22 basic tendon reflexes. So you would -- you can check
23 their tendon reflexes in the forearm and their -- and
24 their knees. And the Babinski sign where you slide a
25 sharp object -- not too sharp -- on their sole and see
121
1 if their toes flex or they extend.
2 Q. Okay. Anything else?
3 A. And the neurologic examination. I think
4 that's most of it. I'm sure I'm missing something,
5 but if I'm evaluating the patient, and if -- let's say
6 if a nurse calls me in, I would do that. I would
7 be -- I would be pretty satisfied with that neuro
8 exam.
9 Q. Okay. First of all, is there anything on
10 here that is beyond the intellectual or physical
11 capacity of the nurses at Emory?
12 MR. LADNER: Object to form.
13 THE WITNESS: I don't think so.
14 Q. (By Mr. Holloway) Okay. So if the nurses
15 are failing to do any part of this, it's because they
16 have not been trained or instructed to do it.
17 A. I guess, yeah.
18 Q. Is there -- to your knowledge, having worked
19 as a physician at one of Emory's primary stroke
20 centers for about five years, has Emory trained the
21 nurses to perform this neurological assessment that
22 you're describing?
23 MR. LADNER: Object to form.
24 THE WITNESS: I do not know.
25 Q. (By Mr. Holloway) It would be good for
122
1 Emory's stroke patients if the nurses did know how to
2 do this; right?
3 MR. LADNER: Object to form.
4 THE WITNESS: True. Or if not know,
5 but if they -- if a complete neuro exam is
6 done that frequently or more frequently.
7 Q. (By Mr. Holloway) How long does it take to
8 do the neurological exam you've described?
9 A. So it can -- I don't know, about ten to
10 15 minutes and you have to have the tools, et cetera,
11 to as well.
12 Q. Let's talk about that. What tools are
13 needed?
14 A. For sensation, a light to look at the
15 pupils. There's also a fork where you can see
16 vibration -- detect vibration, and a hammer for
17 reflexes.
18 Q. Do these tools exist within the hospital at
19 Emory Johns Creek?
20 A. I'm pretty sure they are.
21 Q. Except the --
22 A. Or you either carry or own.
23 Q. When you say fork, you're talking about like
24 a tuning fork; right?
25 A. Yes.
123
1 Q. Okay. So these are not complicated,
2 expensive items, are they?
3 A. Huh-uh (negative).
4 Q. There's no reason that the -- they could not
5 be made available to the nurses, is there?
6 A. I don't think so.
7 Q. Are they made available to the nurses doing
8 neurological assessments at Emory?
9 A. I do not know. Because they don't do the
10 reflexes. Yeah, their neuro exam is very basic. It's
11 basically they're to detect if there's any new
12 neurological symptoms and so they don't do all of
13 that.
14 Q. Let's -- just going through what's on the
15 screen right now. Is there anything on here -- point
16 out to me the items that the nurses do not do.
17 A. Sensory exam is one, sensation, I believe,
18 they don't -- they don't perform that.
19 Q. I'm going to put that in red. So wait. I
20 guess I can't. Hang on. I'll just put in brackets
21 you believe nurses don't do this.
22 A. Sensory, reflexes, ataxia. I think they
23 don't do all the cranial nerves in detail. They
24 basically check for -- they do one, two and a little
25 bit of strength.
124
1 Q. Okay.
2 A. And we can go to Bryan Mays' exam, and it
3 has all the checkmarks on there.
4 Q. Yeah, I want to look at that in a second.
5 But before we do that, I think you've already said
6 this, but I just want to make sure. As you believe
7 that everything on this list is something that Bryan
8 Mays and the other nurses at Emory could -- could do
9 if they were just trained on how to do it and told to
10 do it; right?
11 MR. LADNER: Object -- object to form.
12 THE WITNESS: I guess with sufficient
13 training, yeah. I don't know how long that
14 training would be, et cetera.
15 Q. (By Mr. Holloway) Well, a lot of these
16 things, facial droop, seeing facial droop, certainly
17 the nurses already -- already look for that; right?
18 A. Uh-huh (affirmative).
19 Q. All this stuff on No. 2, talk to the patient
20 to establish alertness, orientation, ability to speak,
21 the nurses already do that; right?
22 A. Yeah, I said they already -- they do one and
23 two.
24 Q. And -- but the cranial nerve exam, they
25 already do the pupil exam; right?
125
1 A. Uh-huh (affirmative).
2 Q. Is that a yes?
3 A. Yes.
4 Q. With facial sensory exam, what are you
5 doing? You're just touching the patient on both sides
6 of the face, asking if they feel it?
7 A. Yeah, and you can also do sharp and dull.
8 Q. Okay. That wouldn't take much training,
9 would it?
10 A. I guess not, no. Yeah, so I guess --
11 Q. Telling the patient make a big smile and
12 then looking at the smile, that would not take a lot
13 of training.
14 A. Yeah.
15 Q. Telling the patient clench your jaw tight
16 and then feeling the muscles and knowing what to look
17 for, they could -- nurses could be trained to do that
18 pretty easily, couldn't they?
19 A. Yes.
20 Q. Telling the patient stick your tongue out
21 and then looking at it and knowing what so look for,
22 nurses could be trained to do that; right?
23 A. Uh-huh (affirmative). Yes.
24 Q. That's not going to take a year in med
25 school to figure out, is it?
126
1 A. No.
2 Q. Telling the nurses look -- have them -- have
3 the patient open the mouth, look at the back of the
4 throat and telling the nurse what to look for, that --
5 that could be trained on easily enough; yes?
6 A. Yes.
7 Q. Close your eyes tight and then -- you're
8 telling the patient to close their eyes tight and then
9 seeing if you can open them with your finger, that
10 would be easy to train the nurses on; yes?
11 A. True.
12 Q. Is there anything on the list -- to make it
13 go a little faster, is there anything on here that
14 you've talked about that you just think is really
15 complicated and it would take just a lot of time for
16 the nurses to understand and become able to do it?
17 A. To the point where I am comfortable enough
18 that that establishes patient's last known normal?
19 Q. Yeah.
20 A. No.
21 Q. That is -- just to make sure I've understood
22 the no. So what you're saying is everything on this
23 list --
24 A. Uh-huh (affirmative).
25 Q. -- the nurses could -- could learn without a
127
1 great deal of difficulty and implement without a great
2 deal of difficulty; true?
3 A. Say that again.
4 Q. Everything -- so we've made this list of
5 things that go into a neurological assessment to
6 identify a last known normal, and am I right that
7 everything on this list, the nurses could learn
8 without much difficulty and could implement without
9 much difficulty?
10 A. Yeah, but this is done to establish last
11 known normal, but we should also understand that we
12 are trying to establish that to determine the
13 treatment; correct?
14 Q. That's -- that's -- that's the understanding
15 I have in asking the question.
16 A. Right. So if I am called by a nurse who
17 tells me that she has done all of that and the
18 patient's symptoms are new and they're within let's
19 say an hour, and she asked me -- or no, she doesn't
20 ask me. So then if you ask me that would I order tPA
21 based off of her assessment, I would say no.
22 Q. So --
23 A. So I would want to -- I would want to go and
24 evaluate the patient myself and establish that.
25 Because I am the one who is going to be ordering tPA,
128
1 and it can take the patient's life away. It can --
2 if -- if they had a small stroke before and their
3 symptoms are intermittent, coming and going, doesn't
4 matter if they're resolving completely or they are
5 waxing and waning or not resolving completely, and if
6 I am -- if you were trying to establish that based off
7 of that -- let's say if that's -- if that is the
8 complete neurological exam that one can do and if
9 nurses do that and if they call me and if I remotely
10 order a tPA for that patient, I would not do that.
11 I would go and evaluate the patient myself
12 and I would use my judgment, use my clinical judgment
13 that this medication that I'm trying to give this
14 patient, which can be effective in taking their
15 symptoms away and which also has a large chance of
16 taking their life away, am I willing to take that
17 risk?
18 I would make that determination by going and
19 seeing that patient myself and establishing that. I
20 would not -- I would not -- unless -- unless -- so
21 people can have different preferences. Unless that is
22 determined by let's say a neurologist who is a
23 trained -- who is a trained physician, let's say if he
24 comes and examines the patient and the patient has
25 come -- is absolutely normal and nurse calls me an
129
1 hour later, okay, and I go and examine the patient and
2 confirm the deficits, I would contact the neurologist
3 and say, Hey, he's having this. I would be -- and if
4 he says the patient did not have any symptoms before,
5 I would trust his evaluation and then I would
6 administer tPA based off of his recommendation.
7 So even if -- so the thing that we need to
8 know and underline and highlight is that the detailed
9 examination that we have went through all of this and
10 established, if a nurse performs that every four
11 hours, I have said from the beginning that does not
12 establish the patient's last known normal. It does
13 not reset the tPA window.
14 Q. Okay. I want to go over some -- a number of
15 things you said there. Give me just a second here.
16 Okay. So first of all, I think you just told me that
17 regardless of how extensive a neurological evaluation
18 the nurse does, you would never rely on the nurse's
19 evaluation to establish the patient's last known
20 normal.
21 A. Personally, I wouldn't.
22 Q. Okay.
23 A. Because if you're -- if we are talking about
24 what are we going to do with that information, if our
25 determination is to base our treatment off of it in
130
1 the sense that we need to give the patient tPA,
2 definitely not. Because it's -- it's such a strong
3 medication that can quickly convert an ischemic stroke
4 into a hemorrhagic stroke.
5 If the nurse says the patient is having a
6 new symptom, I would say, okay, go ahead. I trust you
7 the patient is having a new symptom. Let's do a stat
8 CT head. You see what I'm saying? There's a
9 difference. There's a difference because I'm the one
10 who is prescribing the medication and I do not want to
11 harm my patient. I want to help them.
12 Q. I hear all that. I'm -- I'm -- that goes
13 well beyond the question I asked. I just want to make
14 sure I'm hearing you right. You're saying that
15 regardless and how extensive or good a neurological
16 assessment a nurse does may be, you would never rely
17 on the nurse's assessment to establish the last known
18 well.
19 A. True.
20 Q. Okay.
21 A. And that's what I have said from the
22 beginning.
23 Q. Okay. And that remains true even if it
24 means discarding that assessment is going to cause you
25 to refuse tPA to the patient.
131
1 MR. LADNER: Object to form.
2 Q. (By Mr. Holloway) Right?
3 A. To give tPA, to consider it, I would
4 evaluate the patient myself.
5 Q. Well, you don't have a time travel machine,
6 do you?
7 MR. LADNER: Object to form.
8 THE WITNESS: What do you mean?
9 Q. (By Mr. Holloway) If you get called in
10 because the patient is having symptoms right now --
11 A. Yeah.
12 Q. -- the question for you is in the past --
13 A. Yeah.
14 Q. -- what was the patient's last normal;
15 right?
16 A. Right.
17 Q. You don't have any ability to hop in a time
18 machine, travel to the past and do your own
19 neurological assessment, do you?
20 MR. LADNER: Object to form.
21 THE WITNESS: That would be an ideal
22 situation.
23 Q. (By Mr. Holloway) Let's forget about ideal.
24 Let's talk about the real world. In the real world
25 where we all live, you don't have the ability to go
132
1 back in time and do your own neurological assessment,
2 do you?
3 A. True.
4 MR. LADNER: Object to form.
5 Q. (By Mr. Holloway) So it's either going to
6 be rely on the nurse's assessment or throw that out
7 and say, sorry, Charlie, no tPA for you.
8 MR. LADNER: Object to form.
9 THE WITNESS: I think that's the
10 reason why it's not a standard of care.
11 Q. (By Mr. Holloway) Let's forget about your
12 commentary on the situation. Just tell me am I right.
13 Your position remains, I will continue to disregard
14 the nurse's evaluation even if that means refusing tPA
15 to the patient.
16 MR. LADNER: Object to form.
17 THE WITNESS: No, I would not
18 disregard their -- I would not disregard
19 their findings. Why would you say that?
20 Q. (By Mr. Holloway) For purposes of
21 establishing the last known well, you would disregard
22 the nurse's assessment; yes?
23 MR. LADNER: Object to form.
24 THE WITNESS: No. I would go and
25 evaluate the patient myself at that moment.
133
1 That's why we are in the hospital 24/7. It
2 would take me one minute, two minutes to
3 get there. We are always there on call.
4 We are always there.
5 Q. (By Mr. Holloway) Dr. Chaudhry --
6 A. Yeah.
7 Q. -- if you are called into a patient's room
8 right now because the patient is having stroke
9 symptoms, the question for you is going to be -- on
10 tPA, the question is going to be when was the patient
11 last normal in the past; right?
12 A. Uh-huh (affirmative).
13 Q. That's a yes?
14 A. Yes. Yes.
15 Q. And unless you happen to be the one carrying
16 out the neurological assessments that are ordinarily
17 assigned to nurses, you have no way of going back in
18 time and doing the prior neurological assessment
19 yourself, do you?
20 MR. LADNER: Object to form.
21 THE WITNESS: Yeah, because I would
22 have established the -- the last known
23 normal when I admitted the patient or when
24 the neurologist evaluated the patient and
25 documented it.
134
1 Q. (By Mr. Holloway) Okay. In a situation
2 like Stefan Lane was in where the neurologist didn't
3 show up for about 24 hours, there is no neurologist
4 exam to rely on, is there?
5 A. Yeah, no, there wasn't.
6 Q. And if -- if you did a history and physical
7 when you admitted the patient and then seven hours go
8 by, your having established a last known normal seven
9 hours ago is useless for purposes of tPA; right?
10 MR. LADNER: Object to form.
11 THE WITNESS: Seven hours later, yeah,
12 that's true.
13 Q. (By Mr. Holloway) There's no guarantee in
14 life that if a -- if a post-TIA patient is going to
15 have a stroke that it will just by pure dumb luck
16 happen to be no more than three hours after a
17 physician did a history and physical. There's no such
18 rule in life like that, is there?
19 MR. LADNER: Object to form.
20 THE WITNESS: Yeah, that's why a bunch
21 of them gets discharged from ER.
22 Q. (By Mr. Holloway) I -- right. So it's
23 possible, in fact, in Stefan's situation, he would
24 have been better off if instead of being admitted to
25 the floor he had just been discharged with
135
1 instructions to come back if symptoms returned,
2 wouldn't he?
3 MR. LADNER: Object to form.
4 THE WITNESS: That depends on the ER
5 provider's judgment.
6 Q. (By Mr. Holloway) That wasn't the question.
7 The question is: Stefan would have been better off if
8 they had just discharged him with instructions to come
9 back if symptoms returned instead of being admitted
10 for observation.
11 A. I do not know.
12 MR. LADNER: Object to form.
13 Q. (By Mr. Holloway) That's at least a
14 possibility.
15 MR. LADNER: Object to form.
16 THE WITNESS: I do not know.
17 Q. (By Mr. Holloway) You don't know if it's
18 possible.
19 MR. LADNER: Object to form, asked and
20 answered.
21 THE WITNESS: I don't know.
22 Q. (By Mr. Holloway) Okay.
23 A. Let me ask you this --
24 MR. LADNER: No, no, don't ask him
25 questions. Just answer his questions.
136
1 THE WITNESS: I mean, that --
2 MR. LADNER: Just answer his
3 questions.
4 THE WITNESS: Okay.
5 Q. (By Mr. Holloway) If Stefan had been
6 discharged from the ER with instructions to come
7 back --
8 A. Uh-huh (affirmative).
9 Q. -- let's say six hours later he comes back.
10 They would have asked him when were you last normal;
11 right?
12 MR. LADNER: Object to form.
13 THE WITNESS: Yes.
14 Q. (By Mr. Holloway) And if he said, I was
15 last normal an hour ago, they would rely on that,
16 wouldn't they?
17 A. Yes.
18 Q. Doctors will rely on patient reports of last
19 known normal, but on your testimony, doctors at Emory
20 will not rely on a neurological examination performed
21 by a nurse; true?
22 MR. LADNER: Object to form.
23 THE WITNESS: True.
24 Q. (By Mr. Holloway) So at the time Stefan was
25 admitted for observation, the only chance he had for
137
1 getting tPA from Emory physicians was if he was just
2 lucky enough that his symptoms returned within two or
3 three hours of a physician examination.
4 MR. LADNER: Object to form.
5 Q. (By Mr. Holloway) True?
6 A. True.
7 Q. And you were in a position to know that at
8 the time.
9 A. Yeah.
10 Q. The other doctors at Emory who treat stroke
11 patients, they were in a position to know that at the
12 time.
13 A. I believe so, yes.
14 Q. And nobody breathed a word about that to
15 Stefan or Janet, did they?
16 MR. LADNER: Object to form.
17 THE WITNESS: I believe so.
18 Q. (By Mr. Holloway) You believe I'm correct
19 that nobody said that?
20 A. Yes.
21 Q. Okay. I want to go through some of -- let
22 me go through some of the requests that you gave to
23 questions we submitted to you.
24 MR. LADNER: Dan, I'll just make the
25 same objections that I made in all the
138
1 other depositions; is that okay?
2 MR. HOLLOWAY: Yeah. And you can have
3 a standing objection to it.
4 MR. LADNER: Thank you.
5 Q. (By Mr. Holloway) So do you see a document
6 on the screen?
7 A. Yes.
8 Q. Do you recall seeing this document in the
9 past?
10 A. Yes.
11 Q. And you remember the -- essentially it makes
12 a lot of factual statements and it asks you to say if
13 you admit or deny or don't know?
14 A. Yes.
15 Q. Okay. I'm not going to mark this as an
16 exhibit. I don't think we need that. But here, the
17 responses you gave, I'm not going to go through all of
18 them, but I'll go through a handful. First of all,
19 just so -- so these are -- does this look like your
20 responses?
21 A. Yeah, that's me.
22 Q. No. 11 said, "For interior circulation
23 strokes, tPA generally can be given within a window of
24 up to four and a half hours after the beginning of
25 strokes onset of symptoms following a neurologically
139
1 normal state."
2 And you said -- basically you're -- well,
3 you said, "Although this defendant is generally
4 familiar with the signs and symptoms of a stroke, he
5 would defer to a neurologist for decisions as to when
6 tPA should be administered."
7 I take it that if you had looked, you could
8 have determined whether this statement in No. 11 is
9 true or not; yes?
10 MR. LADNER: Object to form.
11 THE WITNESS: Yes.
12 Q. (By Mr. Holloway) Did you look?
13 A. What do you mean? Look where?
14 Q. Did you make any effort to find out if this
15 statement in No. 11 is true or not?
16 A. Yeah. It is true.
17 Q. No, I'm asking when you gave this response,
18 did you make any effort to find out if this statement
19 is true?
20 A. So, yeah, I -- I actually knew that the
21 statement is true. The reason why I think I responded
22 in that way is because we always consult a neurologist
23 and we discuss the case with them and then before
24 administration of tPA. But if worse comes to worse,
25 if a neurologist is not available for any reason and I
140
1 cannot contact them, I don't -- and I'm running out of
2 time, then I -- I would administer tPA when I felt.
3 Q. Okay. I think you just told me that when
4 you responded to this Request for Admission No. 11,
5 you knew that this statement was true.
6 A. Yes.
7 Q. Okay. But you did not admit that it was
8 true, did you?
9 A. So I answered it based off of the normal
10 practice that we have.
11 Q. Am I right that you did not admit that this
12 statement is true?
13 A. Yes, based off of the response, that's what
14 it seems like. Or it's not in my knowledge or...
15 Q. Okay.
16 A. Yeah.
17 Q. I won't belabor it. You knew it was true
18 but you did not admit it; correct?
19 A. True.
20 Q. Same thing for No. 12, which says, "For
21 patients eligible for tPA, tPA should be given as soon
22 as possible after signs and symptoms of a stroke
23 begin."
24 A. Yeah, I would have the same response.
25 Q. Right. You knew it was true but you did not
141
1 admit it; correct?
2 A. Yes.
3 Q. Same thing for No. 13, which reads, "After
4 the signs and symptoms from the CVA end and the
5 patient returns to a neurologically normal state, the
6 window for tPA therapy resets or reopens."
7 And I'll show you your response. It was the
8 same response as the prior two. This is -- am I right
9 that this is another one where you knew it was true
10 but you did not admit it?
11 A. Yeah. True.
12 Q. Okay. I'll go on. No. 24, it says, "On
13 12/14/17 at approximately 2130 hours, Stefan Lane
14 developed new onset of left-sided neurological
15 symptoms at home." Do you see that?
16 A. Yes.
17 Q. And essentially you said you don't know;
18 right?
19 A. Yeah.
20 Q. Did you do anything to find out whether that
21 statement in 24 is true?
22 A. I think in the -- when the ER called me,
23 they did mention that. I don't remember a specific
24 time when the symptoms started.
25 Q. My question right now is just: When you
142
1 responded to these requests for admission, did you do
2 anything to find out if this statement in No. 24 is
3 true?
4 A. To be honest with you, I don't remember if I
5 reviewed the medical records before answering that or
6 after. I think I reviewed it after, so at that time I
7 didn't know so I answered that way.
8 Q. Sure. Now, you'll notice this footnote
9 here. And the footnote down below, you see that it
10 refers you to the triage note, gives you a page
11 number, code stroke form and page number and the ED
12 physician report and the page number. Do you see
13 that?
14 A. Yes.
15 Q. And let me show you the request again. In
16 the request we said, "To make it easier for you to
17 respond to these requests for admission and to respond
18 timely, for many of the statements we include
19 footnotes with page references. Along with these
20 requests, we're including electronic copies of the
21 medical records that include Bates numbers. The page
22 references in the footnotes refer to those Bates
23 numbers."
24 Now, you see all that?
25 A. Yes.
143
1 Q. Going back to 24, when you responded to
2 this, I take it you did not look at the records that
3 we provided and you did not look at these specific
4 page numbers we directed you to; is that right?
5 A. Yeah, if I responded that, then maybe I did
6 not look or I missed it. I don't remember.
7 Q. Now, you're not a lawyer; right?
8 A. No.
9 Q. And you personally are not familiar with
10 what the law requires when responding to requests for
11 admission.
12 A. Uh-huh (affirmative).
13 Q. You have to say yes or no.
14 A. Yes.
15 Q. Yes meaning you -- you did not know what the
16 law requires; correct?
17 A. Yes.
18 Q. I -- am I right that if the medical records
19 bear out a statement like this in 24, then you don't
20 have any reason to dispute the statement; is that
21 true?
22 MR. LADNER: Object to form.
23 THE WITNESS: I think the confusion
24 probably is coming from -- there was a --
25 there's a -- there is a time that's coming
144
1 to my mind which is 8:30 or 8:40 was when
2 there were symptoms that were started. I
3 don't know where that was. So that's why
4 it's difficult to say that at 2130 there
5 were new symptoms.
6 And if that is coming from the triage
7 note that you suggested, that, to me, would
8 be a continuation of maybe of those
9 symptoms that started at 2040 or 2030.
10 Q. (By Mr. Holloway) Yeah, let me show you --
11 let me show you the page just so we can -- because
12 I -- I understand the point you're making and I think
13 I agree with you. So here is the code stroke form
14 and --
15 A. Yeah.
16 Q. -- for last known well, it says 2040; right?
17 A. Yeah.
18 Q. So the -- I think -- I think the part of the
19 point you were making a moment ago is that the
20 response to this would have been actually it's -- it's
21 true, but the time was approximately 2040 hours.
22 A. I believe so, yeah.
23 Q. That's not what you said; right?
24 A. So that's why I said the question asked if
25 he had new symptoms at 2130. I said I don't know.
145
1 Q. Okay. And you didn't have any way of
2 knowing that the law requires you to admit as much as
3 is true and qualify or deny the part that is not true;
4 right?
5 MR. LADNER: Object to form.
6 THE WITNESS: Yeah, I didn't know
7 that.
8 Q. (By Mr. Holloway) Yeah. I mean, you
9 wouldn't be expected to.
10 A. No.
11 Q. And then, you know, just going down, for
12 example, 26, it reads, "By approximately 2255 hours on
13 December 14th, Mr. Lane's left-sided neurological
14 symptoms resolved and he returned to normal. He was
15 noted at having an NIH stroke score of zero."
16 And again, your response is basically I
17 don't know; right?
18 A. Yeah, and that's based off of that I wasn't
19 there.
20 Q. Right. And you didn't -- you didn't do
21 anything to find out if this statement is true.
22 A. No, I did not. I wasn't told to do so.
23 Q. And you didn't have -- if the -- you could
24 have looked at the records to find out what the
25 records said; right?
146
1 A. Right.
2 Q. And just if the records supported this
3 statement, then you would have no evidence to the
4 contrary.
5 A. Yeah, if it's in the medical records, then
6 yeah.
7 Q. And if the records support it, then you
8 would have no reason to dispute it.
9 A. Yeah.
10 Q. Now, there's a -- there's a bunch of
11 statements like this. I don't want to go through all
12 of them, but, you know, here -- No. 28. This is
13 another statement just based on the records. For all
14 of those, it's going to be the same thing. You -- you
15 didn't look at the records to -- to see whether they
16 support it or not.
17 A. True.
18 Q. And if the records do support it, you would
19 have no basis for disputing the statement.
20 A. True.
21 Q. And that's -- that's just going -- that's
22 going to be the case all the way through these RFAs
23 where there are statements based on the medical
24 records; right?
25 A. True.
147
1 Q. Okay. I think that's all I'll do for that
2 issue. I'm going to move on now to -- this is going
3 to be a lengthy discussion, but just so you understand
4 where I'm coming from, one of -- one of the important
5 things I'm trying to do in the deposition is to pin
6 down basic facts of the case and make sure that I have
7 not misunderstood what I'm reading in the records and
8 to make sure that our side is not going to be
9 surprised by factual disputes when we get to trial.
10 A. Okay.
11 Q. So this is -- this is going to be tedious.
12 Parts of it may be tedious and I apologize for that,
13 but it's a necessary tedium.
14 So I'm going to go through this timeline and
15 make sure that we agree up on basic facts. So just
16 starting -- give me a second. I need to pull out my
17 notes.
18 Okay. So starting on the left, do we -- do
19 we agree that Stefan Lane experienced a mini-stroke at
20 approximately December 14, 2040 hours involving
21 numbness in his left arm and face and difficulty
22 speaking?
23 (Plaintiffs' Exhibit 9 was marked for
24 identification.)
25 THE WITNESS: Yes.
148
1 Q. (By Mr. Holloway) And we agree that at that
2 point, he had a last known well of about 2040 hours?
3 A. Yes.
4 Q. Do we agree that he arrived at the ER on
5 December 14th at about 2225 hours?
6 A. Yes.
7 Q. And for any of these, I can -- more than
8 happy to pull up the record to show you.
9 He was triaged and there was a code stroke
10 form December 14, 2236 hours.
11 A. Yes.
12 Q. They recorded an NIH stroke score of zero at
13 2240 hours.
14 A. Yes.
15 Q. A bed was assigned in the ER at 2253 hours.
16 A. Yes.
17 Q. Nurse John Anderson did a MEND exam at
18 2318 hours that was normal. Setting aside the
19 significance of that for resetting the last known
20 well, can we agree that at least the exam was
21 performed and the nurse recorded no deficits?
22 A. Yes.
23 Q. Okay. But I take it from what you said, you
24 do not believe that would count as resetting the last
25 known well.
149
1 A. True.
2 Q. Okay. So I'll make a note of that. I'll
3 just put not LKW.
4 Okay. Then I may need to show you the
5 report, but there was an HPI taken at a little after
6 midnight, so this would be wrong at least, this
7 December 14th. It would actually be December 15th,
8 0028 hours noting left arm weakness, difficulty
9 speaking and bilateral facial numbness one hour ago.
10 Do you know about that?
11 A. Yes. That is the ER provider's note.
12 Q. Yeah.
13 A. Yeah.
14 Q. Okay. So I want to make sure I'm not
15 recording you as agreeing with language you don't
16 agree with. Let me blow this up. Do you -- first of
17 all, let me fix, that should be 15. And let's -- do
18 you agree with my characterization of that as a second
19 mini-stroke or a second TIA?
20 A. No.
21 Q. Okay. Let me cross that out. But the rest
22 of this, you agree with?
23 A. Yes.
24 Q. So down at the bottom here, I have -- I have
25 this reference to a verified normal in this time range
150
1 in between Nurse Anderson's normal MEND exam and the
2 new symptoms. I take it you do not accept this
3 characterization.
4 A. No.
5 Q. Okay. I'm going to cross that out. While
6 I'm at it, I'll cross out the second mini-stroke
7 reference and these entries, December 15th, a little
8 after midnight, Dr. Chaudhry admits Stefan for
9 observation for brain TIA. You agree?
10 A. Yes.
11 Q. Wrong color.
12 December -- about the same time, Nurse
13 Practitioner McPeak orders patient education on stroke
14 every day. Do you agree?
15 A. Yes.
16 Q. NP McPeak, that's a nurse practitioner in
17 the ER; is that right?
18 A. Yes.
19 Q. Okay. The record around the same time
20 noting that Stefan had a family history of stroke and
21 his mother died of stroke at age 70 and that he had
22 other risk factors including high blood pressure,
23 overweight, heart problems; agree?
24 A. Yes.
25 Q. There's a -- also around the same time
151
1 shortly after midnight, there was a bed request for
2 the admit; right?
3 A. Yes.
4 Q. Now, the -- are you aware that the bed was
5 actually not available until 1705 hours that day?
6 A. Actually, I was not aware of that.
7 Q. You want me to show you that record or --
8 A. No, I believe it.
9 Q. Okay.
10 A. This is not uncommon during the busy times,
11 flu season, et cetera.
12 Q. And you -- of course you're familiar with
13 your -- let me blow that up. You're familiar with
14 your record, but, again, I need to change the 14 to
15 15. And with that correction, we agree that you
16 entered this order for neuro eval every four hours at
17 about midnight 30 on the 15th?
18 A. Yes.
19 Q. Now, I've got this entry at the top here
20 kind of relates back to the one down at the bottom,
21 but we agree that there's this note from Nurse
22 Practitioner McPeak countersigned by Dr. Carrie
23 Edwards saying that at this time, about half an hour
24 after midnight, the degree of the more recent
25 neurological symptoms is minimal.
152
1 A. Yes.
2 Q. And then at about 1:32 a.m., we have your
3 note where you do an NIH stroke score as a result of
4 zero, and you write his symptoms self-resolved and now
5 currently does not have any symptoms, NIH score zero;
6 yes?
7 A. Yeah, that's when I -- most likely when I
8 dictated my note.
9 Q. Okay. You think it relates back to some
10 prior time?
11 A. Yeah, definitely. 'Cause the usual process
12 is that they call us for admission, and then when we
13 can discuss about the admission and then we can accept
14 the admission. Once I accept the admission, then they
15 send a request for admission and then I would place
16 admission orders, basic admission orders. And then I
17 would go and see the patient right away and evaluate
18 them, examine them, take my full history, et cetera,
19 do my whole history taking, and then come back to the
20 working station and then do my note.
21 So I think that time is when I started
22 dictating. So it usually takes about an hour. So
23 probably after placing orders, then I went and saw
24 them. So around 12:30 time I would say would be when
25 I examined.
153
1 Q. Okay. Okay. So with this edit that 1:32 is
2 the dictation time and the exam time may have been
3 around 12:30 a.m. --
4 A. Yeah.
5 Q. -- with that -- with that clarification, is
6 this correct?
7 A. Yes.
8 Q. Now, do you believe that your exam at that
9 point reset the last known normal?
10 A. Yes.
11 Q. To be consistent, I'm going to keep it LKW
12 for last -- last known well.
13 A. Okay.
14 Q. Okay. Now, you're -- you're aware -- are
15 you aware that Dr. Obideen says that your neurological
16 exams are not good enough to reset the last known well
17 either?
18 MR. LADNER: Object to form.
19 THE WITNESS: I guess okay.
20 Q. (By Mr. Holloway) Well, we're --
21 A. I am not aware of that.
22 Q. Okay. You are not aware. Does that change
23 your mind? Do you think he's -- he must be right?
24 MR. LADNER: Object to form.
25 THE WITNESS: That's his personal
154
1 opinion.
2 Q. (By Mr. Holloway) But does his -- does his
3 opinion change your opinion?
4 A. No.
5 (Plaintiffs' Exhibit 10 was marked for
6 identification.)
7 Q. (By Mr. Holloway) Okay. Moving on, at the
8 end here, December 15th, 0530 hours, Nurse Akovi
9 Ajavon makes this note, "Weakness noted to left side.
10 Unable to lift left arm and leg. Weak grip to left --
11 weak grip to left hand. M.D. notified. M.D. wants
12 brain MRI stat." You've seen that record?
13 A. Yes.
14 Q. And you are the M.D. referred to here;
15 right?
16 A. Yes.
17 Q. Now, I have characterized this as the third
18 mini-stroke. I'm guessing you would characterize it
19 as the second?
20 A. Yes.
21 Q. Okay. Let me make that edit.
22 With that modification, is this correct?
23 A. Yes.
24 Q. And then you ordered an MRI of the brain
25 stat at 0530 hours.
155
1 A. Yes.
2 Q. Okay. So that covers some of the basic
3 facts, but now on this section of the timeline, but I
4 have some questions about this.
5 First of all, Stefan comes in at about
6 2225 hours. So about 10:30 p.m.; right?
7 A. Yes.
8 Q. Is there a neurologist scheduled to be in
9 the hospital physically at that time?
10 A. No.
11 Q. If -- now, Dr. Obideen has told us that a
12 lot of the times he still in the hospital because he
13 works longer hours than he's scheduled for, is that
14 your experience?
15 A. Yeah, we have seen him -- we have seen him
16 after hours a lot of times. But he's not formally
17 scheduled as an on-call physician.
18 Q. If -- if he is not -- if he happens to have
19 gone home, I take it there's not another neurologist
20 who is physically in the hospital overnight.
21 A. No.
22 Q. So how do you get a neuro consult if -- if
23 you need 1:00 at night and he's not there?
24 A. There's a tele neurologist who is on call.
25 So they -- we call them. We consult them. We update
156
1 them about the situation and then they'll remotely
2 examine the patient. And there's a camera and a
3 screen which we bring from wherever it's in the
4 hospital to a patient's room and then stand it at
5 bedside and they are able to talk to the patient and
6 ask questions and then do an even more of a basic
7 examination with our help.
8 Q. Now, I think you've said -- oh, I need to --
9 I need to make another change to this to reflect your
10 testimony. This should say two; right? Two
11 mini-strokes in nine hours?
12 A. Yes.
13 Q. Okay. So in your view, this is all one TIA
14 from before Stefan comes into the ER until your neuro
15 exam at 05 -- at some -- sometime not long after
16 midnight; right?
17 A. Right.
18 Q. And so that would be -- he comes in at
19 10:30. So that's about two hours from when he shows
20 up in the door to when you're doing your neuro exam;
21 right?
22 A. Yes.
23 Q. Do you have -- is there an explanation why
24 no neurology consult is called for Stefan in this
25 period when, on your view, he's in -- in the process
157
1 of a TIA?
2 MR. LADNER: Object to form.
3 THE WITNESS: So when I admitted him,
4 his symptoms were already resolved --
5 Q. (By Mr. Holloway) Yeah, I'm going back
6 before your admission.
7 A. I don't know.
8 Q. I understand it's a different situation once
9 you do a neuro exam and the last known well resets.
10 I'm going before that, back in this period.
11 A. Yeah.
12 Q. Where, as I understand it, your testimony is
13 for a couple hours he's involved in a TIA, but
14 there's -- but no neuro consult is called; right?
15 A. Prior to that, yeah, no formal neuro consult
16 was called.
17 Q. Okay. Do you have an explanation for why
18 not?
19 MR. LADNER: Object to form.
20 THE WITNESS: You have to ask them,
21 Dr. Edwards, McPeak.
22 Q. (By Mr. Holloway) If -- okay. So I take it
23 the answer is no, you cannot explain why no
24 neurologist consult was requested in this period
25 between when Stefan arrived at the ER and when you
158
1 evaluated him as normal.
2 A. Yes.
3 Q. If -- now, I understand that he's in the --
4 Stefan is in the ER at this point and your position is
5 going to be you cannot say what the standard of care
6 is in the ER; right?
7 A. Yeah, I don't know.
8 Q. Okay. If -- if this had happened in -- on
9 the medical floor where you work and Stefan was, as
10 you see it, in the process of a TIA that was going on
11 for an hour or more in the hospital and stretched back
12 to about -- well, to 8:40 in the evening, if that --
13 if that had happened on the medical floor, would it
14 have been a standard of care violation not to call for
15 a stat neurology consult?
16 MR. LADNER: Object to form.
17 THE WITNESS: Yeah, if -- if they're
18 still having neurologic symptoms, I would
19 discuss the case with a neurologist and get
20 a formal consult.
21 Q. (By Mr. Holloway) And if we were in the
22 context of the medical floor, it would have been a
23 standard of care violation not to do so.
24 MR. LADNER: Object to form.
25 THE WITNESS: Standard of care
159
1 violation?
2 Q. (By Mr. Holloway) Yes.
3 A. I don't know.
4 Q. Do you know whether, when a patient presents
5 with stroke symptoms that last for -- that are ongoing
6 and that last for more than an hour, does the standard
7 of care require a stat neurology consult at that time?
8 MR. LADNER: Object to form.
9 THE WITNESS: Yeah, that would be a
10 good practice.
11 Q. (By Mr. Holloway) Now, if -- a good
12 practice and required by the standard of care; right?
13 MR. LADNER: Same objection.
14 THE WITNESS: I do not know what the
15 standard of care is in that situation, but
16 I personally would call a neurologist.
17 Q. (By Mr. Holloway) Now, if Dr. Carrie
18 Edwards regarded this MEND exam by Nurse John Anderson
19 as resetting the last known well, that would explain
20 why Dr. Edwards did not request a stat neurology
21 consult, wouldn't it?
22 A. I don't know.
23 Q. Does --
24 A. Maybe -- maybe Justin McPeak examined the
25 patient during that time as well.
160
1 Q. Did -- does an NIH stroke score of zero
2 indicate the patient is neurologically normal?
3 A. I believe so, but I think they can still
4 have some deficit. I cannot think of specific
5 deficit. They could still have an NIH score of zero
6 and still have some neurological deficit.
7 Q. So does an NIH stroke score of zero reset
8 the last known well time?
9 A. No.
10 Q. Sorry. I'm going through my notes trying to
11 see what I can skip.
12 So in this period here when Stefan is in the
13 ER and the nurse has done a MEND exam, nobody at
14 Emory, so far as you know, has done an evaluation that
15 would reset the last known well.
16 A. I don't know what time Justin McPeak saw the
17 patient or Dr. Edwards.
18 Q. I haven't seen a record in which either
19 Justin McPeak or Dr. Edwards performed a neurological
20 exam, have you?
21 A. Would it be part of their H -- HPI or H&P,
22 the ER H&P?
23 Q. Well, it may be, and I suppose after this
24 deposition, I may go back and look. But I guess I
25 want to -- I don't want to spend more time on that. I
161
1 want to move on to the period when you and Dr. Marten
2 were involved. So let me -- well, while we're still
3 on that, one last question, I guess.
4 If -- do you know whether the standard of
5 care requires an ER physician to make sure that a
6 neurological assessment is being done that -- that is
7 capable -- if the patient has no symptoms that is
8 capable of establishing a new last known well?
9 MR. LADNER: Object to form.
10 THE WITNESS: Yeah, I'm pretty sure
11 they do.
12 Q. (By Mr. Holloway) Okay. So if -- if they
13 did not perform a neurological assessment that was
14 capable of establishing a new last known well, that
15 would be a standard of care violation.
16 MR. LADNER: Object to form.
17 THE WITNESS: If they didn't do that,
18 then, yeah, of course.
19 Q. (By Mr. Holloway) Okay. And I take it at
20 the moment at least you cannot direct me to any record
21 where such a neurological assessment or exam is
22 documented in the ER.
23 A. Yeah, I don't know what they documented in
24 their -- in their report, in their note. But when I
25 was called, they told -- I was told that while he's in
162
1 the emergency department, all the symptoms are
2 resolved. So that would be the time before they
3 called me. So there was a provider calling me so
4 pretty sure they evaluated the patient and came to
5 that conclusion to give me that information.
6 Q. Is there a -- is there a record of that
7 call?
8 A. I don't think so, no. They page us and then
9 we call them back.
10 Q. How do you remember that conversation?
11 A. Because it's in my note.
12 Q. Okay. I may have just missed that.
13 A. Yeah.
14 Q. Is it -- is it in your note -- in your note,
15 do you recount the conversation or is it just
16 information from which reading the record you can
17 figure out that there must have been a phone call
18 where they told you this?
19 A. Yeah, so in my HPI, I mentioned that the
20 patient's symptoms were all resolved when he was in
21 the emergency department. So when they give us a
22 sign-out, they give us a sign-out of everything that
23 they know of, and that was -- pretty sure that was
24 also part of it. That's why I documented.
25 Q. Okay. So I think you're talking about this
163
1 document where you wrote his symptoms self-resolved
2 and now currently does not have any symptoms.
3 A. True.
4 Q. Okay. And do you think that you got that
5 information -- you were told that by somebody in the
6 ER or that that was a result of your doing a
7 neurological examination?
8 A. I think I was told that by the provider who
9 was giving me the sign-out and I confirmed when I
10 admitted him.
11 Q. Did you do your own neurological examination
12 to confirm that?
13 A. Yes.
14 Q. Okay. All right. Let me move forward in
15 the timeline. So we've already talked about the first
16 two points here. I won't go back over them. But in
17 your mind, at this point, Stefan is having what may be
18 a stroke; right?
19 MR. LADNER: What time are you talking
20 about?
21 MR. HOLLOWAY: Oh, at -- at 0530,
22 5:30 a.m. when Nurse Ajavon gives you this
23 report.
24 THE WITNESS: Or a TIA.
25 Q. (By Mr. Holloway) A stroke -- right. And
164
1 the difference is just whether it's going to turn out
2 to be temporary or permanent; right?
3 A. Yeah.
4 Q. Okay. So you do not call for a stat
5 neurology consult.
6 A. Yeah.
7 Q. Should you have?
8 A. I don't think so.
9 Q. Why not?
10 A. Because I believe his symptoms are already
11 resolving.
12 Q. Where do you see that? Is there a record
13 that shows that?
14 A. No.
15 Q. I did not see -- I did not see a record
16 anywhere from -- well, actually, until much later in
17 the day at 1652 hours of any neurological assessment
18 by anyone. Have you seen a record that I'm missing?
19 A. I don't think so. I have not reviewed the
20 rest of the day events that happened.
21 Q. Okay. So you don't -- as you sit here right
22 now, you don't know whether there was or was not any
23 neurological examination on the 15th between 0530 and
24 1652 hours.
25 A. No.
165
1 Q. If there -- if there was not any
2 neurological examination in that period, somebody
3 violated their standard of care; right?
4 A. True.
5 Q. I mean, you had already -- you had entered
6 an order for neurological assessments every four
7 hours; right?
8 A. True.
9 Q. And it was the responsibility of the nurses
10 to perform those assessments; right?
11 A. True.
12 Q. Now, you said that -- I think you said the
13 reason that you did not order a stat neurology consult
14 is that Stefan's symptoms were already resolving.
15 A. True.
16 Q. Why do you -- since you don't have any
17 independent memory and you're relying on medical
18 records, where do you see an indication of that in the
19 records?
20 A. Because it's -- if he would have continued
21 to have neurologic symptoms, I would have definitely
22 called a code stroke. I would have asked the tele
23 neurologist to see him. I would have ordered a stat
24 CT scan of the head at that time, and I would have
25 gotten a neurology consult. I believe the symptoms
166
1 were already resolving and I think it was another
2 TI -- it's another TIA just like before that he had --
3 that he had again, and so I wanted to order an MRI of
4 the brain stat, which was initially ordered as a
5 routine MRI which I ordered while I was placing the
6 admission order set.
7 So I asked the nurses to change that to stat
8 so that I can actually see if he was having a stroke
9 or not, and I believe that came back normal.
10 Q. That's the MRI that's listed here at --
11 A. 7:07.
12 Q. Performed at 0707 and the report was signed
13 at 0816 hours?
14 A. Yes.
15 Q. And just to check this off, you -- you agree
16 with that entry on this timeline?
17 A. Yeah. I don't know if it was -- if he had
18 stated there, then it's probably correct. If it was
19 done at 7:07 or was it read at 7:07?
20 Q. Let me show you the document so you can be
21 comfortable and I'm capable of mistakes like anyone.
22 I think 28 was the page number. Here's what I'm -- I
23 might be misreading Emory's forms, but I'm looking at
24 the exam date and time there, 0707.
25 A. That's -- yeah.
167
1 Q. Then let me -- let me show you the signature
2 line. Then we have -- it's dictated, so the signature
3 may be before.
4 A. Electronically signed at 8:16. Okay. Yeah,
5 that's right.
6 Q. Okay. Let me get back to my timeline.
7 Okay. So -- so we talked about the lack of -- or the
8 issue with neuro exams in this period. Did -- did the
9 standard of care require you or Dr. Marten later when
10 he took over -- did the standard of care require
11 either of you to ensure that there would be
12 neurological assessments done adequate to identify the
13 last known well reset?
14 MR. LADNER: Object to form.
15 THE WITNESS: What? Say that again.
16 Q. (By Mr. Holloway) Yeah. Did the standard
17 of care require you to order a neurological assessment
18 that would be reliable to identify a last known well?
19 A. So those are nurses neuro assessments which
20 are ordered every four hours, and that -- they do not
21 establish the last known normal like we discussed
22 before.
23 Q. Right. So my question is: Knowing that,
24 did the standard of care require you to order
25 neurological assessments that would suffice to
168
1 identify a new last known well?
2 A. I believe whatever is ordered is, to my
3 knowledge, the standard of care.
4 Q. Well, you -- taking on your view, the
5 neurological assessments you ordered were not adequate
6 to identify a new last known well; correct?
7 A. Yeah, true. The nurse's assessment, right.
8 Q. So as a matter of fact, you did not order
9 neurological assessments that would suffice to
10 identify a new last known well.
11 A. True.
12 Q. So my question is: Did the standard of care
13 require you to order such assessments?
14 A. I do not know.
15 Q. And nobody at Emory has told you that you
16 are expected to make sure neurological assessments are
17 being done for a post-TIA patient that would suffice
18 to establish a new last known well.
19 A. Yeah, they have told us to use the certain
20 order sets and they have all the standard of care
21 orders in there.
22 Q. Who created those order sets?
23 A. I specifically do not know.
24 Q. Who might know?
25 MR. LADNER: Object to form.
169
1 THE WITNESS: I don't know. Quality
2 control department at Emory.
3 Q. (By Mr. Holloway) Do you know anybody who
4 works in that department?
5 A. At main Emory's campus, no. We do have a
6 quality department at our hospital as well.
7 Q. Is there anybody there who -- if you were
8 trying to figure out who created the order sets, who
9 would you give a call to?
10 A. I would first ask our neurologist, Dr.
11 Obideen, and he can guide me further who to ask.
12 Q. Now, if -- so we've already seen your
13 neurological exam was back -- I mean it was somewhere
14 around 12:30, 1:30 a.m., somewhere in that time frame?
15 A. Yeah. Approximately 12:30.
16 Q. If -- you know, just hypothetically if
17 Stefan had had a major ischemic stroke here at, you
18 know, say 11:15 or so, as you understand it, he would
19 be automatically ineligible for tPA; right?
20 A. Right.
21 Q. Because his last known well based on the --
22 the assessments that you would rely on -- well, there
23 were no assessments between yours a little after
24 midnight -- sometime around midnight, noon 30 and --
25 and my arbitrarily chosen time here, 11:15, there were
170
1 no neurological assessments at all in that period;
2 right?
3 A. True.
4 Q. Okay. So if Stefan had had a major ischemic
5 stroke here, the last known well just would have been
6 too long ago and no chance for tPA for him; right?
7 A. True.
8 Q. I don't want to get off on a whole big thing
9 about this, but Emory had admitted Stefan in part
10 to -- presumably to prevent -- to identify and treat a
11 stroke if he was so unfortunate as to have one; right?
12 A. Right.
13 Q. I mean, this state of affairs where if he
14 has a stroke, he just is ineligible for the first-line
15 treatment, doesn't that strike you as perverse?
16 MR. LADNER: Object to form.
17 THE WITNESS: It would have been ideal
18 if he was admitted in the ICU --
19 Q. (By Mr. Holloway) Should he have been --
20 A. -- where we can do Q1 hour or Q2 hour neuro
21 checks.
22 Q. Should he have been admitted to ICU?
23 A. No, because that's not the standard of care.
24 Q. What's -- what determines whether you get
25 admitted to the ICU or not in a situation like this?
171
1 A. If there's more frequent neuro checks
2 required, that would be one of them. Or if a blood
3 pressure is out of control that requires drips. If
4 they're not protecting their airway which requires
5 advanced airway support.
6 Q. So -- I'm sorry.
7 A. Also, there's -- per nurse -- there's less
8 patients per nurse so they can give more time more
9 frequently to the patients. So all of that matters.
10 Q. So Stefan is now living with -- for the rest
11 of his life, he's going to be living with the
12 disability he has now, and there's an -- in your mind,
13 there's at least a reasonable chance that he could
14 have been spared that if his last known well had been
15 tracked at adequate time intervals so that he could
16 have gotten tPA when he did have a stroke.
17 MR. LADNER: Object to form.
18 THE WITNESS: Yeah. Yeah. In an
19 ideal situation, yes.
20 Q. (By Mr. Holloway) So I want to go back
21 to -- well, you said a moment ago one reason to admit
22 someone to the ICU would be if they need more frequent
23 neurological exams; right?
24 A. Yes.
25 Q. Stefan did need more frequent neurological
172
1 exams, didn't he?
2 A. Looking back at things, maybe. But at that
3 time, if I would have called an ICU team to see,
4 evaluate that patient, I can certainly tell you they
5 would say no, he doesn't mean the -- he doesn't meet
6 the criteria to be admitted in the hospital and they
7 would have said no.
8 Q. What --
9 A. Like I said, right now he would barely
10 meet -- if -- if he can -- at that moment, if he could
11 have walked to the bathroom by himself or with -- with
12 some assistance and he had these symptoms before, he
13 would not even get admitted on the medical floor. He
14 would go to CDU, the observation unit, get the MRI and
15 neurology consult in the morning and -- yeah, so
16 definitely he did not meet the criteria for the ICU
17 admission.
18 Q. What were -- who sets the criteria for ICU
19 admission?
20 A. So again, that would be something for
21 quality department to determine, critical care
22 department.
23 Q. So the -- let me make sure I'm putting this
24 together right in my head. You -- it sounds like you
25 agree with me that -- that what Stefan really needed
173
1 was frequent neurological assessments that would be
2 capable of updating his last known well.
3 MR. LADNER: Object to form.
4 Q. (By Mr. Holloway) We agree so far?
5 A. Yes.
6 Q. But the place at Emory Johns Creek, the unit
7 that could provide those continuous updates, the
8 assessments to do those updates is the ICU.
9 A. If you want to do it more than four hours or
10 more frequent than four hours, then yes.
11 Q. And the problem, though, is that he couldn't
12 get into the ICU because of the criteria for ICU
13 admission.
14 A. Yes.
15 Q. And that's -- that was out of your hands.
16 A. Yeah.
17 Q. Are those -- those -- I'm sorry. I didn't
18 mean to interrupt.
19 A. At that moment, looking at everything at
20 that moment, I would also not consider him to be an
21 ICU patient. You always want to weigh risk versus
22 benefits; right? The more critical place you are
23 admitted in, the more illnesses you can contract and
24 develop and there are consequences for it. So you do
25 not want to risk your patients to be in a higher level
174
1 of care than what they actually need.
2 Q. Okay. Let's --
3 A. They can develop pneumonias in the ICU,
4 delirium, et cetera. There's a whole list of things.
5 Q. Let's do some risks of ICU admission. You
6 mentioned basically we're talking hospital-acquired
7 infections.
8 A. Yes.
9 Q. For example is pneumonia. Was there another
10 example you gave me?
11 A. C. diff, which is a bowel infection. Two
12 Fs. And...
13 Q. What other risks of ICU admission?
14 A. Delirium.
15 Q. Anything else?
16 A. I can't remember of anything else, but I'm
17 sure there are more.
18 Q. Okay. Now let's make a list of risks of
19 let's just say non-ICU admission. So tell me if I'm
20 right. No neuro assessments to update last known
21 well. That's a risk; right?
22 MR. LADNER: Object to form.
23 THE WITNESS: By the nurses, but
24 physicians can.
25 Q. (By Mr. Holloway) Well, you weren't doing
175
1 hourly or -- or every-two-hour neuro assessments, were
2 you?
3 A. No, but I would get called by nurse
4 immediately if she sees any -- any deficit.
5 Q. Sure.
6 A. And then I would evaluate and that would
7 include a neuro assessment.
8 Q. Of course, but that neuro assessment doesn't
9 do anything to tell you -- that does not keep the last
10 known well updated as he -- as time goes on; right?
11 A. Yeah, so you can say no routine physician
12 neuro assessment to update last known normal.
13 Q. No routine -- well, no routine neuro
14 assessments at all to update last known well; right?
15 A. Yeah, but it can be an exception when the
16 nurse calls you, right? So that's not routine.
17 But -- but when a nurse calls you, then you would do a
18 physician evaluation.
19 MR. LADNER: And, Dan, the record
20 speaks for itself, which is why I objected
21 to this. But he said no routine physician
22 neuro assessments if you want to be
23 accurate.
24 MR. HOLLOWAY: No, I -- yeah. I
25 caught that. I want to see if I --
176
1 Q. (By Mr. Holloway) Dr. Chaudhry, I want to
2 see if I can talk you out of it because frankly I
3 think you're wrong.
4 MR. LADNER: Object to form,
5 argumentative.
6 Q. (By Mr. Holloway) Whether -- there is --
7 admitted to the medical floor, there is no routine
8 neuro assessment to update last known well, period,
9 full stop; correct?
10 A. By the nurses.
11 Q. By anyone. You're not -- who is -- what
12 physician is doing routine neuro assessments to update
13 the last known well?
14 MR. LADNER: Object to form.
15 THE WITNESS: When I -- like I said,
16 when we round, when we do daily rounds,
17 when the neurologist does their round.
18 Q. (By Mr. Holloway) No neurologist came in to
19 see --
20 A. Yeah, not this in this situation, but you're
21 talking in general; right?
22 Q. Well, the --
23 A. The statement that you're making?
24 Q. Neurologists don't -- I'm sorry.
25 A. Excuse me?
177
1 Q. I'm sorry. I thought you were done. Go
2 ahead.
3 A. No, go ahead.
4 Q. Well, just to cut it short, no routine neuro
5 assessments to update last known well by physicians,
6 and I guess it makes sense to add that because on your
7 view, physicians are the only ones who can do an
8 assessment to update the last known well; correct?
9 A. True.
10 Q. Okay. So that means then there's the risk
11 that if a major ischemic stroke happens, tPA may be
12 I'll just say out of window; is that fair?
13 A. Yes.
14 Q. So unless a thrombectomy is indicated, the
15 patient has no acute treatment options for a major
16 stroke; is that true?
17 A. Yes.
18 Q. And the consequences of that could be
19 serious lifelong disability or death; true?
20 A. True.
21 Q. Let me put a note on this. I think this is
22 No. 3.
23 MR. LADNER: I'll object to the
24 exhibit.
25 MR. HOLLOWAY: Sure.
178
1 MR. LADNER: Dan, we've got about
2 another hour left and I need about a
3 five-minute break at some point soon, so
4 just head's up.
5 MR. HOLLOWAY: Let's go ahead and take
6 a break right now.
7 THE WITNESS: Okay.
8 (A recess was taken.)
9 Q. (By Mr. Holloway) Okay. Dr. Chaudhry,
10 let's -- let me go back to the timeline we were
11 looking at. One second while I put it up. Okay.
12 So I think when -- right before we left, we
13 were talking about admission to the ICU versus non-ICU
14 and we went through risks of each. Going back to the
15 criteria that -- the fact of the matter is just that
16 under the criteria that Emory imposes for ICU
17 admission, Stefan -- there was nothing you could do to
18 get Stefan into the ICU?
19 A. Yeah, that's true. He would not meet the
20 criteria to be in the ICU.
21 Q. Okay. So he had to stay on the medical
22 floor and on the medical floor you have a standard
23 order set for -- for TIA patients or post-TIA
24 patients.
25 A. Yes.
179
1 Q. And that standard order set provides for
2 neurological assessments by the nurses every four
3 hours.
4 A. Yes.
5 Q. Okay. Now, your shift runs from 7:00 p.m.
6 to 7:00 a.m. on this -- this day, December 14th and
7 15th?
8 A. From 9:00 p.m. till 7:00 a.m.
9 Q. Okay. And you did -- we already looked at
10 the point on the timeline where you did your
11 assessment somewhere around midnight, 1:00 a.m.
12 A. Yeah. Yeah. 12:30 approximately. Yeah.
13 Q. Now, did the standard of care require you to
14 do another neurological assessment at any time from
15 then until 7:00 a.m. when you hand off the patient?
16 A. No.
17 Q. It could be very useful, very good for the
18 patient if you did another neurological exam.
19 A. Definitely, yes.
20 Q. But in your -- as you understand it, the
21 standard of care did not require you to do so.
22 A. Yeah, no. Because I have approximately 125,
23 120 other patients that are -- that I'm taking care of
24 at that time.
25 Q. Right. So if you -- if -- in this situation
180
1 if you and other physicians cannot rely on the
2 neurological assessments by the nurses to update the
3 last known well and the patient's not in the ICU, then
4 Stefan is just out of luck when it comes to having his
5 last known well updated.
6 MR. LADNER: Object to form.
7 THE WITNESS: Yeah. You can say yeah
8 because of the number of physicians and
9 nurses in the hospital. During the
10 daytime, we have several teams who take
11 care of patients, but at night, it's just
12 me so...
13 Q. (By Mr. Holloway) Now, in -- on the
14 timeline here, December 15th around 0900 hours, you
15 ordered a stroke score every 12 hours; right?
16 A. I don't know if I ordered it at that time.
17 It's probably going to be part of the order set.
18 Q. Let me see if I can pull up the record I was
19 looking at. 153. Here's where I was looking at when
20 I wrote that. Stroke education, order start. Entered
21 by you -- yeah, that's right. So the start date or
22 the start time was 0900, but you entered it shortly
23 after midnight.
24 A. Yes, if it was part of the order set.
25 Q. Got it. Okay. And that'll -- that'll be
181
1 the same story I'm thinking for the stroke score.
2 A. Yes.
3 Q. Let's just pull that up. So the 0900 was a
4 start time, but you entered it shortly after midnight.
5 A. Uh-huh (affirmative).
6 Q. Let me -- let me just make a note to that
7 effect. Okay. With that addition, these entries
8 would be correct?
9 A. Yes.
10 Q. Now, so we talked about -- you said you do
11 not think the standard of care required you to do
12 another exam on your shift. When Dr. Marten comes in,
13 he comes in sometime around 7:00 a.m.; right?
14 A. Yes.
15 Q. So when he takes over the patient, does the
16 standard of care require him to do a neurological exam
17 of Stefan?
18 A. Yeah, when he rounds and when he sees all
19 the patients that he has.
20 Q. Now, this -- I need to go back. Going back
21 to before 7:00 a.m. So you said that the reason you
22 did not order -- the reason you didn't call a code
23 stroke and go through all of that process is that
24 Stefan's symptoms were already reducing; right?
25 A. Yes.
182
1 Q. And then there's this MRI that shows no
2 evidence of a stroke; right?
3 A. Yes.
4 Q. Do you believe that his symptoms ended
5 sometime around or before the time of the MRI?
6 A. Yes.
7 Q. If you had done -- if you were or Dr. Marten
8 had done a neurological examination around then, do
9 you believe it would have reset the last known well?
10 MR. LADNER: Object to form.
11 THE WITNESS: A detailed examination,
12 yeah.
13 Q. (By Mr. Holloway) As it happens, nobody
14 documented such an exam, so for Dr. Obideen if he came
15 in around, you know, in the evening of that day, there
16 would be nothing in the record for him to look back
17 on; right?
18 A. Yeah.
19 Q. Okay. So going back to Dr. Marten, the
20 standard of care you said required Dr. Marten to do a
21 neurological exam; right?
22 A. Right.
23 Q. Did it require him to document his
24 neurological exam?
25 A. It would be -- it would be ideal if he
183
1 documented that as well.
2 Q. I understand, but I'm not asking about
3 what's ideal. The question is what the standard of
4 care requires. In your view, did the standard of care
5 require Dr. Marten to document his neurological exam?
6 A. I do not know.
7 Q. At minimum, we can agree that you do not --
8 you do not have an affirmative belief that there is no
9 such requirement. You just don't know.
10 A. Yeah, I don't know.
11 Q. Is it the normal practice to document
12 neurological exams that you perform?
13 A. Yes.
14 Q. Is that the normal practice among
15 hospitalists at Emory generally?
16 A. Yes.
17 Q. So you would expect that if Dr. Marten did a
18 neurological exam he would document it?
19 A. True.
20 Q. Now, going forward, at some point you're
21 aware that Dr. Marten sends a text message to
22 Dr. Obideen requesting a neurology consult?
23 A. Yeah, I believe so.
24 Q. And at that time, Dr. Marten -- I can show
25 it to you if you'd like me to. But Dr. Marten tells
184
1 Dr. Obideen that Stefan is having symptoms, persistent
2 symptoms. Are you generally aware of that?
3 A. Yes.
4 Q. Okay. Now, do you believe based on what we
5 discussed earlier from around the -- the symptoms at
6 5:30 a.m. and the MRI at 7:00, if Dr. Marten at some
7 later time is seeing neurological symptoms in Stefan,
8 do you believe that represents a new onset of
9 symptoms?
10 A. Yeah.
11 Q. Okay. Now, going forward in the -- well,
12 when Dr. Marten becomes aware of new neurological
13 symptoms, does the standard of care require him to
14 document that in the medical record?
15 A. Yes. That would be ideal.
16 Q. And whether he did an initial neurological
17 exam or not, when he learns that now the patient has
18 neurological symptoms again, does the standard of care
19 require him to do a neurological exam at that time as
20 well?
21 A. Yes.
22 Q. Now, moving forward, the -- this -- are you
23 familiar with this neurological assessment by Nurse
24 Michael Kelly at 1652 hours?
25 A. No.
185
1 Q. Okay. Just to save time, I think I won't
2 bother showing you the record, but it is your view
3 that this would not -- normal or not, whatever
4 neurological assessment Nurse Kelly does, there's no
5 way it can reset the last known well for purposes of
6 tPA therapy.
7 A. No. No. They can have sensory deficits.
8 Q. Right. So this -- for purposes of the last
9 known well, this assessment might as well not even
10 exist; true?
11 A. True.
12 Q. But to Nurse Kelly's credit, at least he's
13 now performing a regular assessment pursuant to your
14 order.
15 A. True.
16 Q. Good on him for that.
17 A. Yes.
18 Q. Let's move forward in the timeline. So this
19 is later that day. We're still on the 15th. And
20 you're familiar with a bunch of the records from late
21 night on December 15th; right?
22 A. Yes.
23 Q. So we already talked about this, but the --
24 the neuro assessment by Nurse Bryan Mays, again, for
25 purposes of the last known well and tPA, that
186
1 assessment might as well not exist; true?
2 A. Yes. True.
3 (Plaintiffs' Exhibit 11 was marked for
4 identification.)
5 Q. (By Mr. Holloway) And then going forward,
6 you're familiar with the fact that Stefan had a severe
7 headache and he became very hypertensive around 2043
8 and 2120?
9 A. Yes.
10 Q. Okay. Are you aware of anybody having done
11 a neurological exam after Stefan developed this
12 ten-out-of-ten headache?
13 A. I am not.
14 Q. Should somebody have done a neurological
15 assessment in -- when Stefan developed this
16 ten-out-of-ten headache and became very hypertensive?
17 A. Ideally, yeah.
18 Q. Okay. It would have been good for Stefan if
19 such an assessment had been done.
20 A. Yes.
21 Q. Do you agree with me that headache and very
22 high blood pressure are often -- not always, but often
23 associated with ischemic stroke?
24 A. Yes, they can be.
25 Q. It's entirely possible in your mind, is it
187
1 not, that around this time when Stefan has this severe
2 headache and hypertension, if a neurological exam had
3 been done, it would have revealed neurological
4 deficits?
5 MR. LADNER: Object to form.
6 THE WITNESS: If he had them at that
7 time, yeah.
8 Q. (By Mr. Holloway) And if neurological
9 deficits had been done -- or I'm sorry.
10 If a neurological exam had revealed
11 neurological deficits, then the normal response would
12 have been to call a code stroke.
13 A. Yes.
14 Q. And a code stroke would have prompted -- we
15 know that sort of by chance Dr. Obideen -- even though
16 it's coming up on 9:30 at night, 10:00 at night, even
17 though it's getting late, we happen to know that
18 Dr. Obideen is still in the building; right?
19 A. Yes, he came and saw them at that time.
20 Q. Yeah. So if a code stroke had been called
21 around 2043 hours, 2120 hours, sometime in there,
22 Dr. Obideen would have come running.
23 A. Yeah, if he was in the building.
24 Q. And you would -- one of the reasons why we
25 have protocols called code stroke or stroke alert is
188
1 because it gets people focused on the -- the urgency
2 of the problem.
3 A. True.
4 Q. If Dr. Obideen had come running in response
5 to a code stroke, there's no way to say precisely what
6 that would have done in his mind, but do you expect
7 that it would have -- he would have felt a sense of
8 urgency that he would not normally feel when doing a
9 routine consult.
10 MR. LADNER: Object to form.
11 THE WITNESS: I don't know.
12 Q. (By Mr. Holloway) Do you recall -- so just
13 moving forward in the -- in the story here. Around
14 sometime around 2300 hours, 11:00 p.m., the timing is
15 a little imprecise because of the difference between
16 when an exam is done and when it's dictated and
17 signed; right?
18 A. Yeah. Yeah.
19 Q. So we don't know the exact timing. But
20 somewhere around 2200, 2300, Dr. Obideen shows up;
21 right?
22 A. Yes.
23 Q. Do you remember anything about his
24 appearance and examination of Stefan Lane?
25 A. I actually do not.
189
1 Q. Do you know -- do you have any memory of
2 being in Stefan's room when Dr. Obideen arrived?
3 A. I actually do not.
4 Q. Okay.
5 A. It's been so long.
6 Q. Sure. Going back a little bit to your
7 involvement. At -- at 22 hours on the 15th, you
8 ordered a stat CT of Stefan's head; right?
9 A. Yes.
10 Q. And why did -- why did you order that?
11 A. Because he was having severe headache which
12 was new and which was not going away, and it was also
13 associated with high blood pressure. I was more so
14 worried about a bleed because ischemic stroke can also
15 have tendency to convert into hemorrhagic strokes. So
16 therefore basically wanted to rule that out and so I
17 ordered a stat CT head.
18 Q. The -- so there's this phrase "thunderclap
19 headache" that is associated with hemorrhagic stroke;
20 right?
21 A. Uh-huh (affirmative).
22 Q. You have to say the word.
23 A. Yes.
24 Q. What are the symptoms of a hemorrhagic
25 stroke?
190
1 A. Similar to ischemic stroke, it can be focal
2 deficits, or depending on the bleed. If it's a big
3 bleed, if it's an arterial bleed, they can just bleed
4 inside and basically the skull gets -- skull doesn't
5 move, so it just bleeds -- arterial pressure is so
6 high it just pushes the brain and you can even
7 herniate the brain so...
8 Q. Did you do a neurological evaluation of
9 Stefan around the time you ordered the CT?
10 A. I did not.
11 Q. Why did you not?
12 A. Because I believe I was told that the
13 neurologist is already there and they are evaluating
14 the patient.
15 Q. Do you -- is there any record that reflects
16 that?
17 A. If it's not there, then I don't think so.
18 Q. Do you have an independent memory of being
19 told that?
20 A. I do not.
21 Q. I'm -- am I right that that explanation
22 you're kind of putting that together because of the
23 timing of the CT order and when Dr. Obideen entered
24 his consult note?
25 A. True.
191
1 Q. Okay. Now, the CT that you ordered stat
2 showed no evidence of acute infarction; right?
3 A. Yes.
4 Q. And that means no evidence of dead brain
5 tissue; is that right?
6 A. On the CT scan which is a very limited exam.
7 Q. Sure. But that's what it means, no acute
8 infarction.
9 A. Yes. But it's not definitive, though. You
10 can't make diagnosis off that. Yeah.
11 Q. Sure. I mean, it's entirely possible that
12 there was a stroke in process that was killing brain
13 tissue, but the CT isn't sensitive enough to have
14 shown -- shown it.
15 A. Yes, basically more so to differentiate
16 between an ischemic and a hemorrhagic stroke.
17 Q. And then the -- are you familiar with the --
18 the radiology report for the CTA -- let me back up.
19 From the consult note that we looked at
20 earlier from Dr. Obideen, you know that he ordered a
21 CTA of Stefan; right?
22 A. Yes.
23 Q. And that -- that CTA showed no large-vessel
24 obstruction; right?
25 A. Yes.
192
1 Q. And we touched on this earlier, but a
2 mechanical thrombectomy is at least best suited for
3 pulling clots out of large vessels.
4 A. Yes.
5 Q. So if Stefan -- excuse me.
6 If Stefan is having an ischemic stroke in
7 here, this is really maybe contrary to what it seems
8 like at first glance. This CTA result is really bad
9 news for him because it means his -- his stroke cannot
10 be fixed with a thrombectomy; right?
11 MR. LADNER: Object to form.
12 THE WITNESS: Yeah.
13 Q. (By Mr. Holloway) And it's even worse news
14 because on your view at least he's automatically
15 disqualified from tPA because there has been no
16 neurological assessment at any time since -- since
17 shortly -- you know, whenever you did yours shortly
18 after midnight of the 14th. There hasn't been a
19 single neurological assessment to reset his last known
20 well, so tPA is out as an option; right?
21 A. Yes. True.
22 Q. So in this situation, essentially Stefan is
23 just doomed.
24 MR. LADNER: Object to form.
25 THE WITNESS: Yeah. That's very
193
1 unfortunate.
2 Q. (By Mr. Holloway) I mean, if -- if only
3 this neurological assessment had been done by somebody
4 capable of doing an assessment that resets the last
5 known well, that would have made a big difference.
6 MR. LADNER: Object to form.
7 THE WITNESS: Yeah.
8 Q. (By Mr. Holloway) It would have meant that
9 Stefan could have received the clot-buster medication
10 that would break up the stroke that was killing parts
11 of his brain.
12 MR. LADNER: Object to form.
13 THE WITNESS: In that specific
14 situation, no, he would not be a tPA
15 candidate.
16 Q. (By Mr. Holloway) Why not?
17 A. Because his blood pressure was too high.
18 Systolic blood pressure above 180 is a
19 contraindication.
20 Q. Does medical science furnish any medications
21 for reducing blood pressure?
22 A. Yes.
23 Q. Very commonly people with ischemic strokes
24 who are tPA candidates, they have high blood pressure
25 that has to be brought down with medication.
194
1 A. True.
2 Q. Is there any reason why Stefan would not
3 have been able to receive medication to lower his
4 blood pressure?
5 A. He did receive it.
6 Q. Right. So he was not contraindicated for
7 it.
8 A. Yeah, it increases the risk of bleeding,
9 rupturing an artery, converting an ischemic into
10 hemorrhagic stroke and becomes an even bigger risk.
11 Q. Yeah, every stroke patient -- with every
12 stroke patient you have to balance risks and benefits;
13 right?
14 A. Definitely, yes.
15 Q. It's a little bit like going back to the ICU
16 example we talked about earlier.
17 A. Uh-huh (affirmative).
18 Q. On the one hand you have to -- on the one
19 hand you have the risk of letting a stroke go
20 untreated and letting parts of the brain die and
21 ending up with lifelong serious disability or death.
22 And then on the other hand you have the other risks;
23 right?
24 A. Yes.
25 Q. Stefan isn't -- Stefan was not unique in
195
1 having risks on both sides, was he?
2 A. No.
3 Q. But if this exam by Nurse Mays, if that had
4 been the kind of exam that was reliable to reset the
5 last known well, then you and Dr. Obideen could have
6 gone to Stefan and said, Here are your options, here
7 are your risks, what would you like to do.
8 A. True.
9 Q. And then Stefan and Janet could have had --
10 could have had some say in what was going to happen to
11 them.
12 MR. LADNER: Object to form.
13 THE WITNESS: True.
14 Q. (By Mr. Holloway) But as it was, they had
15 no say because the medical providers at one of Emory's
16 primary stroke centers did not do neurological
17 assessments that in your view would reset the last
18 known well.
19 MR. LADNER: Object to form.
20 THE WITNESS: Yeah, 'cause the nurse's
21 assessment doesn't -- it doesn't determine
22 the last known normal, and if he had
23 received that tPA at around 2230, he
24 probably -- there would be a chance that
25 he's not even here. So I believe they
196
1 didn't want -- they didn't want to take
2 that chance because it's life-threatening.
3 It's death. That's the other risk. It's
4 death. You herniate your brain. You bleed
5 from everywhere. From your eyes, your
6 ears, your nose, from every end. That's
7 the risk that you have to weigh all of that
8 against. The neurological judgment of
9 everyone else and everybody's examination.
10 You have to rely on that.
11 Q. (By Mr. Holloway) Let me make sure I know
12 what you're talking about. You said if he had
13 received tPA around 2230.
14 A. Yeah, around that time when I think that is
15 when Dr. Obideen examined and documented his consult
16 note and he mentioned that he had left-sided weakness,
17 zero-out-of-five strength.
18 Q. And in saying if he had received tPA there
19 he might have died from hemorrhage and brain
20 herniation, you're going back to the blood pressure
21 point; right?
22 A. Or if he had any residual deficits at --
23 prior to that, any sensory deficit, any facial sensory
24 deficit.
25 Q. Let's take one issue at a time. So you're
197
1 raising two issues. You're saying he might die if --
2 if he gets tPA while his blood pressure is still this
3 high; right?
4 A. Yes.
5 Q. Okay. But as you've already admitted, the
6 blood pressure can be lowered with medications; right?
7 A. Yes.
8 Q. Okay. So that's one issue. The other issue
9 that you mentioned was he might -- despite this normal
10 neuro exam by Nurse Mays, who Emory hires to do
11 assessments on their stroke patients at one of their
12 primary stroke centers, despite that, maybe he really
13 did have some neurological deficits we don't know
14 about.
15 A. Yeah, he could have.
16 Q. Okay. Well, the way to know that would have
17 been to have Emory train their nurses to do proper
18 neurological exams; right?
19 MR. LADNER: Object to form.
20 THE WITNESS: Yeah, and as soon as
21 they find anything abnormal, call the
22 provider right away who can establish that
23 and confirm that.
24 MR. HOLLOWAY: Objection to the
25 nonresponsive part of that, which was
198
1 everything after the "yeah."
2 (Plaintiffs' Exhibit 12 was marked for
3 identification.)
4 Q. (By Mr. Holloway) So let's move forward in
5 the timeline. I don't know that I need to have you
6 address all of this. This is -- this is the 16th you
7 see there. But just -- is it -- is it not remarkable
8 to you that even after everything that was happening
9 late night on the 15th, we then go into the morning of
10 the 16th and we go 12 hours without a neurological
11 assessment.
12 MR. LADNER: Object to form.
13 THE WITNESS: It gets -- it's not
14 there. It's very unfortunate.
15 Q. (By Mr. Holloway) It's a -- it is
16 unfortunate. It's also a standard of care violation.
17 MR. LADNER: Is that a question?
18 MR. HOLLOWAY: Yes.
19 MR. LADNER: Objection.
20 THE WITNESS: Yes, if it's not done,
21 it's very unfortunate.
22 Q. (By Mr. Holloway) And a standard of care
23 violation; right?
24 A. Yes.
25 Q. And as I read the records, the first time
199
1 anybody does any stroke education is 12:15 on the
2 16th. I'm not going to show you the record to confirm
3 that, but if -- if I'm right about that, that's also a
4 standard of care violation; right?
5 A. True.
6 Q. I mean, just globally here, Emory is
7 dropping the ball all over the place, isn't it?
8 MR. LADNER: Object to form.
9 THE WITNESS: Yeah, I don't know what
10 the specific situation was and why it
11 happened.
12 Q. (By Mr. Holloway) Did -- well --
13 A. I don't know why it happened, what the
14 situation was. I don't know which fall season it was,
15 but it was time when people -- people would be in the
16 emergency department at Emory University Hospital, at
17 Emory Midtown Hospital for up to 48 hours. So I don't
18 know. That's not -- I don't remember what the
19 specific situation was.
20 (Plaintiffs' Exhibit 13 was marked for
21 identification.)
22 Q. (By Mr. Holloway) Do you -- do you know of
23 anything that was going on that created unusual
24 difficulty in treating Stefan Lane?
25 A. I don't remember at all. It's almost three
200
1 years ago.
2 Q. Okay. You cannot identify any -- any factor
3 that made it unusually difficult to comply with -- for
4 the various providers at Emory to comply with their
5 standards of care.
6 A. Yeah, ideally documentation could have been
7 better, consults could have been called much earlier,
8 evaluations should have been done more often.
9 Q. I'm asking a different question. I'm asking
10 if you know of any facts or circumstances that made it
11 super hard for Emory's physicians and nurses to do
12 their jobs properly with Stefan Lane?
13 A. I do not know.
14 Q. So are you familiar with the MRI report that
15 was for the MRI that was finally done on
16 December 17th?
17 A. Yes.
18 Q. And it showed a stroke; right?
19 A. Yes.
20 Q. It showed dead brain tissue deep in Stefan's
21 brain; right?
22 A. Yes.
23 Q. And then I don't know if you would be -- if
24 you've seen this or not, but at least it won't
25 surprise you to learn that Dr. Obideen writes a
201
1 progress note later that confirms the stroke; right?
2 A. Yes.
3 (Plaintiffs' Exhibit 14 was marked for
4 identification.)
5 Q. (By Mr. Holloway) And then just to close
6 this out on the 18th, which is a Monday, as I see the
7 records, nothing happens that's relevant to treatment
8 of a stroke. Did you see anything that happened on
9 December 18th relevant to treatment of a stroke?
10 A. I do not know. I didn't review.
11 Q. And, I mean, it's really -- it's kind of
12 a -- in a way it's a silly question because it's too
13 late; right? Right?
14 A. For that specific stroke that happened
15 previously or to determine how to prevent more stroke
16 from happening?
17 Q. Yeah, I'm talking about to treat the stroke
18 that has -- has occurred while Stefan is supposedly
19 under observation by physicians and nurses at one of
20 Emory's primary stroke centers.
21 A. Yes, something happened prior to 2200 of the
22 15th.
23 Q. I'm -- we're not -- the question and answer
24 are not meeting. By -- let me go back to it.
25 By the time Monday, December 18th comes
202
1 around, it is too late to treat the stroke that has
2 killed tissue deep inside Stefan Lane's brain.
3 A. Yes.
4 Q. And then the next day, Tuesday,
5 December 19th, Dr. Obideen writes an addendum. Have
6 you read the addendum?
7 A. I have not.
8 (Plaintiffs' Exhibit 15 was marked for
9 identification.)
10 Q. (By Mr. Holloway) I know it's not worth our
11 time right now to show it to you, but he -- in
12 discussing the last known well -- I'm going from
13 memory here so I'm not going to ask you to assume the
14 truth of anything I say here. But my memory of it is
15 he says that consistent with what you've been saying
16 here today, Stefan was never a candidate for tPA, and
17 in that discussion he doesn't mention any of the
18 neurological assessments by nurses.
19 And that's consistent with your position and
20 your testimony today that the neurological assessments
21 by nurses are of no use in updating the last known
22 well; right?
23 MR. LADNER: You've got to say yes or
24 no.
25 THE WITNESS: Yes.
203
1 Q. (By Mr. Holloway) Just to finish up here.
2 The -- the care that Stefan got or did not get while
3 at Emory worked out badly for Stefan and Janet, didn't
4 it?
5 A. Yes.
6 Q. And the thing about that is that the outcome
7 was entirely predictable from the very beginning if,
8 on your view, there is no way to update a patient's
9 last known well by having nurses do neurological
10 assessments.
11 MR. LADNER: Object to form.
12 Q. (By Mr. Holloway) Am I right?
13 A. Right.
14 Q. I mean, as you tell it, everybody involved
15 except Stefan and Janet knew there was no way Stefan
16 was going to get tPA if he had another stroke.
17 MR. LADNER: Object to form.
18 THE WITNESS: True. If he didn't meet
19 the criteria.
20 Q. (By Mr. Holloway) Right. Unless -- unless
21 he just got lucky and by pure dumb luck a later stroke
22 just happened to be not long after a physician did a
23 neurological assessment, if he got lucky in that
24 respect, then maybe he would be eligible for tPA, but
25 otherwise, he might as well have had a stroke in an
204
1 alley behind a supermarket for all the good it would
2 do him if he wanted acute treatment for a stroke.
3 MR. LADNER: Object to form.
4 THE WITNESS: Yeah.
5 Q. (By Mr. Holloway) Do you think Stefan and
6 Janet had a right to know what they were getting into
7 when they went with the decision to have Stefan
8 admitted for observation at Emory?
9 MR. LADNER: Object to form.
10 THE WITNESS: Yeah.
11 Q. (By Mr. Holloway) Dr. Chaudhry, I
12 appreciate your -- your candor in this discussion and
13 I think -- I don't mean to presume, and I apologize if
14 I'm presuming, but the sense I'm getting at this end
15 of the videoconference is that you are not happy with
16 the way the system worked. Am I right?
17 MR. LADNER: Object to form.
18 THE WITNESS: There can be
19 improvements, definitely, but I would also
20 be very -- very confident despite this
21 unusual situation, pretty confident in
22 saying that we do our best in providing
23 care and the quality of care that we give.
24 Q. (By Mr. Holloway) Well, would it be better
25 for patients like Stefan Lane or, you know, the
205
1 next -- the next retired schoolteacher who comes in
2 having had a TIA or the next church organist who comes
3 in having had a TIA or whoever for all of the future
4 patients who are going to -- who think that Emory is a
5 good stroke hospital, for all of those patients who
6 come in having had TIAs, would it be a good thing if
7 Emory trained their nurses so that the nurse
8 neurological assessments could be relied on for
9 updating the last known well?
10 MR. LADNER: Object to form.
11 THE WITNESS: We establish that they
12 would not -- if they do their test, exam,
13 detailed exam, I would still have to
14 confirm that by myself. Otherwise, how
15 unreasonable would it be if a nurse calls
16 me saying, I'm doing my neuro exam, and I
17 have done a detailed exam and the patient
18 has a new deficit right now and without
19 evaluating the patient myself, am I ever
20 going to be comfortable enough to prescribe
21 tPA? No.
22 Q. (By Mr. Holloway) Because -- go ahead.
23 A. Because -- because I can cause death. It's
24 not that you're going to develop a rash and then it
25 will be over and I'll give you Benadryl or steroids
206
1 after that. It's not that. It's not an antibiotic.
2 And -- and the uncertainty in this is so much that
3 even, like, maybe I was feeling numbness here, can
4 contribute to it because that could mean that there
5 was an ischemic stroke happening whether it's from a
6 clot or it's from an artery spasming, and the part of
7 the brain that suffered at that time can eventually
8 bleed if I give you tPA. You have to understand that.
9 Q. So what you're saying is at least for you,
10 Dr. Abrar Chaudhry, no nurse in the world could do a
11 neurological examination that you would rely on for
12 updating the last known well because they're a nurse,
13 not a doctor.
14 A. Not enough for me to personally prescribe
15 tPA. I'm sorry, no.
16 Q. Right. If you're -- no matter how highly
17 trained, no matter how careful, no matter how
18 diligent, no matter how qualified, no nurse
19 examination is good enough for you to reset the last
20 known well even if taking that position means the
21 patient is disqualified from tPA and doomed to just
22 suffer whatever effect a stroke causes.
23 MR. LADNER: Object to form.
24 Q. (By Mr. Holloway) Have I --
25 A. Not to -- not to reset the tPA clot, no. I
207
1 would not -- I would not trust that because the
2 consequence is much higher. Consequence is death. So
3 I do not want to risk that.
4 MR. HOLLOWAY: Objection,
5 nonresponsive.
6 Q. (By Mr. Holloway) Did I correctly state
7 your position?
8 MR. LADNER: Object to form, asked and
9 answered.
10 THE WITNESS: True.
11 Q. (By Mr. Holloway) And you are telling us
12 that that position you're taking, that is the way
13 it -- that's not just you. That's the way it happens
14 at Emory.
15 MR. LADNER: Object to form, calls for
16 speculation.
17 THE WITNESS: I believe so, yes.
18 Q. (By Mr. Holloway) Let me ask you this: If
19 Emory -- if Emory decided that as a matter of policy
20 they wanted to -- to set out a policy that
21 neurological assessments performed by properly trained
22 nurses would be treated as resetting the last known
23 well, if they did that, would you follow that policy?
24 MR. LADNER: Object to form.
25 THE WITNESS: If it's backed by
208
1 standard of care and if it's done more
2 frequently, but I don't know. I would
3 still have to think about it, whether it
4 would be enough for me to prescribe tPA
5 myself.
6 Q. (By Mr. Holloway) Okay. You might have --
7 A. The risk.
8 Q. You might or might not follow that policy?
9 A. If they develop it, then they would do it if
10 it's standard of care, backed by research, et cetera,
11 et cetera. So I just cannot answer a hypothetical
12 question like that.
13 Q. You don't know if you would -- okay. So you
14 don't know whether or not you would follow that
15 policy.
16 MR. LADNER: Object to form.
17 THE WITNESS: If it's backed by
18 research, we would get informed about it by
19 the department, et cetera, by the quality
20 department, neurology department, emergency
21 department. And if it happens like that,
22 formally, all throughout the system, Emory
23 system, then, yeah, then I would -- then I
24 would -- then I would follow it. I would
25 have to look at the detailed exam that they
209
1 do. I would -- I would also see whether --
2 how the nurses are being trained, et
3 cetera.
4 Q. (By Mr. Holloway) So maybe you would follow
5 that policy, but it's all a hypothetical because Emory
6 has no such policy.
7 A. Of what, for the nurses to do their
8 neurological exam to set the last known normal, no.
9 Q. And as far as you understand it, Emory is
10 100 percent behind the approach you believe in, which
11 is no nurse can do a neurological exam reliable to
12 reset the last known well.
13 MR. LADNER: Object to form.
14 THE WITNESS: True.
15 Q. (By Mr. Holloway) It was that -- it's that
16 way back in December of 2017. It's that way today in
17 August 2020.
18 MR. LADNER: Object to form.
19 THE WITNESS: True, they don't
20 determine the last known normal.
21 Q. (By Mr. Holloway) And you don't have any --
22 you see no indication that Emory has any intention of
23 changing that going forward for future post-TIA
24 patients.
25 MR. LADNER: Object to form.
210
1 THE WITNESS: I have not heard about
2 that.
3 MR. LADNER: Dan, it's 5:00.
4 MR. HOLLOWAY: It's 4:47.
5 MR. LADNER: I've got 5:00.
6 MR. HOLLOWAY: I think that's -- I
7 think that's good enough for today.
8 Dr. Chaudhry, I don't have any more
9 questions unless Mr. Ladner has some
10 follow-up and then I might have a couple.
11 MR. LADNER: I do not.
12 MR. HOLLOWAY: Okay. Dr. Chaudhry,
13 thank you for your time.
14 THE WITNESS: You're welcome.
15 MR. HOLLOWAY: You take care.
16 THE WITNESS: Thanks a lot.
17 MR. HOLLOWAY: Off the record.
18 (Deposition concluded at 4:58 p.m.)
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211
1 DISCLOSURE
2
Pursuant to Article 10.B of the Rules
3 and Regulations of the Board of Court
Reporting of the Judicial Council of
4 Georgia which states: "Each court reporter
shall tender a disclosure form at the time
5 of the taking of the deposition stating the
arrangements made for the reporting
6 services of the certified court reporter,
by the certified court reporter, the court
7 reporter's employer or the referral source
for the deposition, with any party to the
8 litigation, counsel to the parties, or
other entity. Such form shall be attached
9 to the deposition transcript," I make the
following disclosure:
10
I am a Georgia Certified Court
11 Reporter. I am here as a representative of
Huseby Global Litigation. Huseby Global
12 Litigation was contacted to provide court
reporting services for the deposition.
13 Huseby Global Litigation will not be taking
this deposition under any contract that is
14 prohibited by O.C.G.A. 9-11-28(c).
15 Huseby Global Litigation has no
contract/agreement to provide reporting
16 services with any party to the case, any
counsel in the case, or any reporter or
17 reporting agency from whom a referral might
have been made to cover this deposition.
18
Huseby Global Litigation will charge
19 its usual and customary rates to all
parties in the case, and a financial
20 discount will not be given to any party to
this litigation.
21
22
Blanche J. Dugas
23 CCR No. B-2290
24
25
212
1 STATE OF GEORGIA:
2 COUNTY OF FULTON:
3
4 I hereby certify that the foregoing
5 transcript was reported, as stated in the
6 caption, and the questions and answers
7 thereto were reduced to typewriting under
8 my direction; that the foregoing pages
9 represent a true, complete, and correct
10 transcript of the evidence given upon said
11 hearing, and I further certify that I am
12 not of kin or counsel to the parties in the
13 case; am not in the employ of counsel for
14 any of said parties; nor am I in any way
15 interested in the result of said case.
16
17
18
19
20 BLANCHE J. DUGAS, CCR-B-2290
21
22
23
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213
1 CAPTION
2
3 The Deposition of ABRAR CHAUDHRY, M.D.,
4 taken in the matter, on the date, and at the time and
5 place set out on the title page hereof.
6 It was requested that the deposition be
7 taken by the reporter and that same be reduced to
8 typewritten form.
9 It was agreed by and between counsel and
10 the parties that the Deponent will read and sign the
11 transcript of said deposition.
12
13
14
15
16
17
18
19
20
21
22
23
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214
1 CERTIFICATE
2 STATE OF GEORGIA
3 COUNTY OF FULTON
4 Before me, this day, personally appeared,
5 ABRAR CHAUDHRY, M.D., who, being duly sworn, states
6 that the foregoing transcript of his deposition, taken
7 in the matter, on the date, and at the time and place
8 set out on the title page hereof, constitutes a true
9 and accurate transcript of said deposition.
10
11 _________________________
12 ABRAR CHAUDHRY, M.D.
13
14 SUBSCRIBED and SWORN to before me this
15 _______day of_________________, 20___ in the
16 jurisdiction aforesaid.
17
18 _____________________ ________________________
19 My Commission Expires Notary Public
20
21 *If no changes need to be made on the following two
22 pages, place a check here ____, and return only this
23 signed page.*
24
25
215
1 DEPOSITION ERRATA SHEET
2
3 Our Assignment No. 303330
4 Case Caption: Lane vs. Emory Healthcare, et al.
5
6 Witness: ABRAR CHAUDHRY, M.D. - 08/17/2020
7 DECLARATION UNDER PENALTY OF PERJURY
8 I declare under penalty of perjury that I have read
9 the entire transcript of my deposition taken in the
10 captioned matter or the same has been read to me, and
11 The same is true and accurate, save and except for
12 changes and/or corrections, if any, as indicated by me
13 on the DEPOSITION ERRATA SHEET hereof, with the
14 understanding that I offer these changes as if still
15 under oath.
16
17 Signed on the ______ day of
18 ____________, 20___.
19
20 ___________________________________
21 ABRAR CHAUDHRY, M.D.
22
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1 DEPOSITION ERRATA SHEET
2 Page No._____Line No._____Change to:______________
3 __________________________________________________
4 Reason for change:________________________________
5 Page No._____Line No._____Change to:______________
6 __________________________________________________
7 Reason for change:________________________________
8 Page No._____Line No._____Change to:______________
9 __________________________________________________
10 Reason for change:________________________________
11 Page No._____Line No._____Change to:______________
12 __________________________________________________
13 Reason for change:________________________________
14 Page No._____Line No._____Change to:______________
15 __________________________________________________
16 Reason for change:________________________________
17 Page No._____Line No._____Change to:______________
18 __________________________________________________
19 Reason for change:________________________________
20 Page No._____Line No._____Change to:______________
21 __________________________________________________
22 Reason for change:________________________________
23
24 SIGNATURE:_______________________DATE:___________
25 ABRAR CHAUDHRY, M.D.
217
1 DEPOSITION ERRATA SHEET
2 Page No._____Line No._____Change to:______________
3 __________________________________________________
4 Reason for change:________________________________
5 Page No._____Line No._____Change to:______________
6 __________________________________________________
7 Reason for change:________________________________
8 Page No._____Line No._____Change to:______________
9 __________________________________________________
10 Reason for change:________________________________
11 Page No._____Line No._____Change to:______________
12 __________________________________________________
13 Reason for change:________________________________
14 Page No._____Line No._____Change to:______________
15 __________________________________________________
16 Reason for change:________________________________
17 Page No._____Line No._____Change to:______________
18 __________________________________________________
19 Reason for change:________________________________
20 Page No._____Line No._____Change to:______________
21 __________________________________________________
22 Reason for change:________________________________
23
24 SIGNATURE:_______________________DATE:___________
25 ABRAR CHAUDHRY, M.D.